One of the leading cognitive models of auditory verbal hallucinations (AVHs) proposes such experiences result from a disturbance in the process by which inner speech is attributed to the self. Research in this area has, however, proceeded in the absence of thorough cognitive and phenomenological investigations of the nature of inner speech, against which AVHs are implicitly or explicitly defined. In this paper we begin by introducing philosophical phenomenology and highlighting its relevance to AVHs, before briefly examining the evolving literature on the relation between inner experiences and AVHs. We then argue for the need for philosophical phenomenology ( Phenomenology) and the traditional empirical methods of psychology for studying inner experience ( phenomenology) to mutually inform each other to provide a richer and more nuanced picture of both inner experience and AVHs than either could on its own. A critical examination is undertaken of the leading model of AVHs derived from phenomenological philosophy, the ipseity disturbance model. From this we suggest issues that future work in this vein will need to consider, and examine how interdisciplinary methodologies may contribute to advances in our understanding of AVHs.
Detailed suggestions are made for the direction and methodology of future work into AVHs, which we suggest should be undertaken in a context where phenomenology and physiology are both necessary, but neither sufficient. Inner experience and AVHs Although there are many models of AVHs, such as memory-based models (Waters et al., ), hypervigilance models (Dodgson and Gordon, ), and social deafferentation models (Hoffman, ), we will focus in this paper on how philosophical phenomenology may be applied to what is currently the dominant model (in terms of being the most empirically investigated, as well as most discussed) model of AVHs, the inner speech model. This model proposes that AVHs result from a disturbance to the process whereby inner speech is attributed to the self (e.g., Frith,; Leudar et al., ).
However, progress in this area has been hampered by a lack of attention to the phenomenological properties of inner speech and, relatedly, AVHs. In particular, there is a need for improved empirical research on key properties of inner speech that have been proposed to be of value in explaining the relation between inner speech and AVHs (Fernyhough,; Jones and Fernyhough, ). One such factor is dialogicality, which refers to the ability of inner speech to incorporate multiple perspectives on reality (Fernyhough, ). Dialogicality has been proposed to result from the development of inner speech through the internalization of structured linguistic exchanges with caregivers and others during the course of development (Vygotsky,; Fernyhough, ). This quality of inner speech has been proposed as an explanation for why AVHs often manifest voices of others alongside that of the self (Fernyhough,; Jones and Fernyhough, ). A second important quality is condensation, the tendency of utterances in inner speech sometimes to appear phenomenally as having a condensed or “note-form” quality. Condensation has been proposed as a further reason why inner speech can take multiple forms, such as in the proposed distinction (Fernyhough, ) between “condensed inner speech” (in which the internal utterance is fully stripped-down and abbreviated) and “expanded inner speech” (in which internal utterances retain their full linguistic structure).
Transition between forms of inner speech (condensed and expanded) has been put forward, in an extension of the basic inner speech model of AVHs, to explain why voices can suddenly intrude into consciousness (Fernyhough, ). The empirical study of inner speech has of course been hampered by its unobservability. Some support for the dialogicality and condensation dimensions of inner speech was provided by McCarthy-Jones and Fernyhough who, using a self-report scale (the Varieties of Inner Speech Questionnaire), found the existence of these dimensions in a healthy sample of adults. Other empirical methods proving useful in the study of inner speech are dual-task methods in which the language system is temporarily blocked by, for example, articulatory suppression, and experience sampling methods such as the phenomenological Descriptive Experience Sampling (DES; Hurlburt and Heavey, ). There has been little research on the phenomenological properties of inner speech and AVHs in those who hear voices.
In the only study to provide a systematic analysis of inner speech phenomenology alongside AVH phenomenology, Langdon et al. found no significant differences in inner speech phenomenology between people diagnosed with schizophrenia who heard voices and non voice-hearing healthy controls. For example, there were no differences between the two groups in the form, speed, and pragmatics of their inner speech, and no relations between patients' inner speech and their voices in terms of variables such as frequency and pragmatics. However, there was a trend toward reduced dialogicality of inner speech in the patient group (in the sense of inner speech being less likely to take on an overt dialogic form), potentially suggesting a relation between a reduced normal inner dialogue and the presence of AVHs.
Of course, inner speech only forms a subset of inner experiences (Hurlburt and Heavey, ), and a recent study of the phenomenology of AVHs has suggested that a diverse range of inner experiences, such as verbal and non-verbal memories, as well as inner speech, may form the basis of AVHs. McCarthy-Jones et al.
assessed the phenomenology of AHs in 199 psychiatric patients, using an interviewer-led semi-structured interview. “ Phenomenology” and “ phenomenology” The empirical methods of psychology for studying inner speech and other forms of inner experience such as AVHs entail clear limitations. Retrospective introspection of the form demanded by self-report studies is likely to be unreliable in certain circumstances, while dual-task methods gain little traction on phenomenology and rely on potentially misplaced assumptions about the recruitment of inner speech in cognitive tasks. Although DES is founded in phenomenological principles and is careful to ensure the bracketing of presuppositions, it can be criticized for its failure to generate generalizable empirical data.
Philosophical phenomenology, which we denote here as Phenomenology (phenomenology with a big “P”), can potentially enrich the methods of self-report, introspection, etc. That psychologists and cognitive scientists have traditionally relied on, which we refer to as phenomenology (phenomenology with a small “p”). Phenomenology can supplement and enrich phenomenology because the former works at a distinct but nevertheless complementary level of analysis to the latter. That is, whereas phenomenology and its methods of self-report, introspection, etc.
Introduction To Phenomenology Pdf
Yield important data about the specific contents of experience (i.e., what a subject is experiencing), Phenomenology is—in addition to this data—also concerned with the formal structures of experience (i.e., how the subject is experiencing the “what”). This “transcendental” aspiration is essential to Phenomenological methodology (Husserl, ). Again, this transcendental aspiration is apparent in Phenomenology's concern with how basic structures inherent in consciousness (e.g., intentionality, self-awareness, temporality, embodiment, spatiality, agency, intersubjectivity, etc.) organize and constitute experience and imbue it with a first-personal character. Data from phenomenological reports (e.g., patient vignettes in psychiatry) can lend important clues to how and where these basic structures become compromised or disrupted within anomalous experience. However, Phenomenology can further contextualize these often fragmentary or isolated reports within a broader transcendental context. This is because Phenomenology offers a sophisticated framework for describing experience and existence that enables the psychopathologist to address concrete issues of diagnosis and treatment while remaining mindful of how these local concerns relate to overarching issues such as time, space, self, and intersubjectivity (Parnas and Zahavi, ). Accordingly, Phenomenology does not simply consider symptoms in isolation (i.e., as localized manifestations of brain dysfunction); nor does it reduce diagnostic entities to statistically relevant clusters of symptoms (Fuchs, ).
Rather, these are considered in the broader context of the subject and the whole of consciousness in which they emerge, that is, as typical modes of human experience and existence through which the subject constitutes her experience of self, world, and other. As Thomas Fuchs notes, this structural emphasis of Phenomenology is a search for what he terms “psychopathological organizers” connecting single features (e.g., affective depersonalization in melancholic depression or autism in schizophrenia) within a larger experiential gestalt. This emphasis “helps define mental disorders on the basis of their structural experiential features, linking apparently disconnected phenomena together” (Fuchs, p. The end result—in light of these complementary levels of analysis—is that phenomenology and Phenomenology can together provide a richer and more nuanced picture of the phenomenon under consideration than can either approach on its own. The ipseity model of AVHs One attempt to utilize phenomenological philosophy to help understand AVHs has come from Sass and Parnas. An examination of their resultant account of AVHs is informative of the strengths and limitations of the application of phenomenological philosophy to AVHs.
Their model involves a phenomenological analysis of ordinary experience, as well as that experienced by people with AVHs, and then the use of this analysis to propose what processes may be underpinning AVHs. Sass and Parnas's approach is derived from a phenomenological analysis of two facets of the intentional act: (1) a pre-reflective embeddedness in the world, and (2) a tacit or pre-reflective self-awareness or ipseity (literally, “self” or “itself”). The term “ipseity” refers to the experiential sense of being a subject of experience, i.e., one's own first-person perspective on the world. The basic sense of ipseity in normal consciousness, argues Sass , is reflected in someone “whose experiences are unified and owned rather than merely flying about loose” (p. Sass and Parnas argue that there are occasions, such as in schizophrenia, where this basic sense of self or ipseity becomes fragmented or otherwise disturbed. In the case of schizophrenia, disturbed ipseity exhibits two main features. The first is hyper-reflexivity, a form of exaggerated self-consciousness in “which something normally tacit becomes focal and explicit” (p.
For example, some patients report that normally tacit sensorimotor processes animating everyday behavior (e.g., getting dressed, drinking coffee, interacting with others, etc.) may lose their automaticity. Instead, the background repertoire of proprioceptive and kinaesthetic processes informing this behavior move to the foreground of the patient's focal attention; they become hyper-aware of the effort required to produce each gesture or movement—so much so that their body is eventually experienced as a mechanical object, resulting in an experience of disembodiment or “self-alienation” (p. Alternatively, other patients report that particular details of a scene, or specific qualities of faces or persons, stand out with a kind of hypersalience; they are dislodged from the gestalt of the situational context and thus appear strange or uncanny (Wiggins and Schwartz, ). Even the perceptual act itself may rise to the level of focal awareness (e.g., “I became aware of my eye watching an object,” Stanghellini, p. Hyper-reflexivity thus objectifies normally tacit, pre-reflective processes of agency and perception. In a later paper (Nelson et al., ), the authors make clear that although hyper-reflexivity is a concept that includes an exaggerated intellectual or reflective process, it is not “at its core, an intellectual, volitional, or ‘reflective’ kind of self-consciousness. It primarily refers to acts of awareness that are automatic (non-volitional) and not intellectual in nature, as in the case of kinaesthetic experiences ‘popping’ into awareness” (Nelson et al., p.
As hyper-reflexivity makes focal what was once tacit, the experience can hence not be transparently inhabited by the self; hyper-reflexivity introduces a rupture within the basic structure of experience. This leads to the second, complementary component of ipseity disturbance: a diminishment of self-affection, which Sass and Parnas define as a reduction in the sense of basic self-presence; “the implicit sense of existing as a vital and self-possessed subject of awareness” (p. For example, patients may report feeling an inner distance from their stream of consciousness (“I saw everything I did like a film-cameram” Sass, p.132), or “an inner void” or “lack of inner nucleus” where the self would normally be (Parnas and Handest, ).
As ipseity disturbances, hyper-reflexivity and diminished self-affection thus erode the basis sense of self-presence and perspectival coherence that enables us to maintain an experiential grip on the world and on ourselves as embedded in the world. Sass and Parnas propose that AVHs (and schizophrenia more generally) result from such an ipseity disturbance. They argue that in texts such as Ey , Tissot , Naudin et al. , an altered state of self-awareness can be seen to occur before AVHs. Specifically, they argue that “the patient experiences his or her own subjectivity as becoming in a certain way ready for something strange to happen Mental processes and inner speech are no longer permeated with the sense of selfhood but have become more like introspected objects, with increasingly reified, spatialized, and externalized qualities” (p.
Commonly encountered AVHs, such as voices commenting on a hearer's on-going behavior, are, in Sass and Parnas' view, “emblematic of the self-consciousness that generates this self-alienation.” From this they conclude that AVHs “involve a sense of alienation from and a bringing to-explicit-awareness of the processes of consciousness itself.” Sass argues that this occurs through “an automatic popping-up or popping-out of phenomena and processes that would usually remain in the tacit background of awareness” (Sass, p. As such they “do not involve the addition of anything new but only an awareness of what is always present (e.g., of inner speech, the perfectly normal medium of much of our thinking) in the context of diminished self-presence” (Sass and Parnas, p. In their view, AVHs therefore “represent the perfectly normal phenomena of ordinary human experience—which, however, are radically transformed because of being lived in the abnormal condition of hyper-reflexive awareness and diminished self-affection” (p. Specificity to AVHs A second limitation is that despite the apparent argument made for a causal role of ipseity in AVHs, in a later paper Sass and colleagues (Nelson et al., ) argue that “ipseity disturbance seems to be independent of symptom manifestation,” still being present in the remitted phase of schizophrenia, hence making it a “trait or underlying marker of vulnerability, independent of the expression of this vulnerability in the form of psychotic symptoms” (p. Similarly, Garcia-Montes et al.
observe that high levels of “self-focused attentions are not exclusive in patients with auditory hallucinations, but that, in general, they characterize all patients with positive psychotic symptoms.” This could be interpreted as the proponents of this theory arguing that ipseity disturbances are a necessary, although not sufficient cause of AVHs. However, Sass focusses on AVHs in people diagnosed with schizophrenia, which is not only a contested diagnostic entity (Boyle, ) but a diagnosis that only contains around a third of people who hear voices (McCarthy-Jones, ). It could therefore potentially be the case that ipseity disturbances are linked to schizophrenia per se and have no causal relation with AVHs. It is also possible that ipseity disturbances are not found in other populations who hear voices, and are therefore not necessary for AVHs, and even if ipseity disturbances were found to be a necessary but not sufficient cause for AVHs, this would still leave the question as to what other additional factors are required for AVHs to ensue. Finally, it is also possible that in some populations or situations ipseity disturbances may be sufficient for AVHs. For example, the presence of AVHs in people undertaking intense introspection, such as the Desert Fathers (Christian monks in the third century who retired to the deserts of Egypt to pray: McCarthy-Jones, ) is at least suggestive that self-focus might be a sufficient cause of some AVHs. Empirical testing and levels of explanation At present there is very limited empirical evidence supporting Sass's ipseity account of AVHs.
Although Sass was originally explicit that his account was “largely descriptive or interpretative rather than explanatory in nature” (p. 244), a more recent paper by Sass and colleagues (Nelson et al., ) has gone on to make some specific hypotheses, such as that the ipseity model predicts “an increase in self-focusing as causing a tendency to experience the object of focus as other-than-self (i.e., externalising or objectifying self-experience)” (p. Linking this to a neurological level of explanation, they further state that this account “would predict that psychotic phenomena should be associated with increased cortical midline system (CMS) activity, to the extent that the disturbances of hyper-reflexivity and diminished self-affection suggest an increase in self-focusing as causing a tendency to experience the object of focus as other-than-self” (p. Although phenomenological work leading to predictions at a neurological level is a promising way forward (see below), unfortunately for this specific hypothesis, activation of such structures during AVHs was not found in a recent meta-analysis (Jardri et al., ). A recent paper by Garcia-Montes et al. considers the relation between Sass and Parnas's work and contemporary cognitive psychology.
Garcia-Montes et al.' S overall argument is that there are noticeable parallels between “hyper-reflexivity” and some cognitive models of schizophrenia/AVHs that concentrate on attentional processes in such patients. However, it is unclear quite how Sass and Parnas's concept of hyper-reflexivity maps onto established psychological constructs. One possibility is that it relates to the psychological concept of meta-cognition (Garcia-Montes et al., ), which includes a range of items, including cognitive self-consciousness.
However, a recent meta-analysis of the association between of meta-cognition and hallucination-proneness found only a weak association (Varese and Bentall, ). Nevertheless, what can be seen from this is that phenomenological philosophy needs to engage with (and potentially extend or revise), existing psychological constructs, in order to operationalize and test hypotheses that phenomenological philosophy has generated. A further empirical limitation of this account is that other theories of AVHs predict the exact opposite to Sass and Parnas. For example, Dodgson and Gordon argue that hypervigilance AVHs result specifically when attention is externally focussed. There is hence the need for an empirical investigation into the locus of attention of voice-hearers immediately preceding AVHs, which should be a priority for future experience-sampling studies of this phenomenon. Benefits in terms of informing neurocognitive research Although there is the need for phenomenological philosophy to engage with the concepts of existing neurocognitive work, it is also worth considering how it may extend these paradigms through critique. For example, Sass and Parnas's model can be considered in relation to the source-monitoring account of AVHs.
Source-monitoring accounts of AVHs argue that a deficit in the skill of being able to distinguish between self-generated internal cognitions and non self-generated external perceptions leads the former to be mistaken for the latter, resulting in AVHs (Bentall, ). “Source monitoring” is used as a global term to cover both reality monitoring (the ability to differentiate between internally generated cognitions and external perceptions) and self-monitoring (the ability to differentiate between self- and other-produced stimuli). Although Sass and Parnas state that their account is “rather different” (p. 432) to the established self-monitoring deficit account of AVHs, they do not clearly set out their points of difference (in a later paper, they state that self-monitoring accounts are “redolent” of their ipseity model; Nelson et al., ). In either case, Nelson et al.
note that source-monitoring studies often require a reflective judgement about the source of a stimulus, making it unclear whether conscious self-reflection or the pre-reflective processes emphasized in their phenomenological accounts of ipseity disturbance in schizophrenia are being assessed. This inconsistency in experimental tasks may be able to account for the limitations in the existing psychological source-monitoring literature, which is somewhat contradictory.
For example, whilst a recent meta-analysis has suggested specificity of source-monitoring deficits to AVHs (Waters et al., ), other studies have instead suggested that it is delusional ideation, not AVHs, that is linked to source-monitoring deficits (Allen et al.,; see McCarthy-Jones, for a review of the current evidence). There is hence the need for further consideration as to whether source-monitoring tasks involve conscious self-reflection or pre-reflective processes, and to examine these two separate forms of source-monitoring in relation to AVHs specifically, to see if both, neither or just one of these is related to them.