The following article is an introduction to the Research Topic on Frontiers in Psychology: Cognitive Science: Towards an embodied science of intersubjectivity: Widening the scope of social understanding research.

This is an interesting article and a very cool research area.

Full Citation: 
Di Paolo, EA, and De Jaegher, H. (2015, Mar 2). Toward an embodied science of intersubjectivity: Widening the scope of social understanding research. Frontiers in Psychology: Cognitive Science. 6:234. doi: 10.3389/fpsyg.2015.00234

Toward an embodied science of intersubjectivity: Widening the scope of social understanding research

Ezequiel A. Di Paolo^* and Hanne De Jaegher

• Logic and Philosophy of Science, IAS-Research Centre, University of the Basque Country, Donostia/San Sebastián, Spain

The study of human social phenomena in their proper scope demands the integrated effort of many disciplinary traditions. This fact is widely acknowledged but rarely acted upon. It is in practice often difficult to cross disciplinary boundaries, to communicate across different vocabularies, research goals, theories and methods. The aim of this Research Topic has been to make some progress in stepping across these borders.

Not attempting this crossing in a subject as multi-faceted as intersubjectivity inevitably binds us to remain within self-enclosed conceptions. By this we mean a bundle of self-reinforcing perspectives, hypotheses, experimental methods, debates, communities and institutions. Traditional ways of thinking about social cognition frame the questions that are deemed worth researching. These all revolve around the issue of how we figure out other minds, assuming that other people's intentional states are hidden, private and internal. The proposed answers rely only on how the perceived indirect manifestations of other people's mental states are processed by individual cognitive mechanisms (Van Overwalle, 2009).

We would like to raise, instead, the question of what an embodied science of intersubjectivity would look like if we were to start from different premises than those that delimit classical approaches to social cognition. For doing this, we thought the time was ripe for bringing together work that crosses disciplinary boundaries and informs us about different conceptions of how people understand each other and act and make meaning together.

The move is timely. The internalist assumptions in social cognition research are beginning to shift. We have more and better tools to explore the role of interactive phenomena and interpersonal histories in conjunction with individual processes (Dumas et al., 2010; Di Paolo and De Jaegher, 2012; Konvalinka and Roepstorff, 2012; Schilbach et al., 2013). This interactive expansion of the conceptual and methodological toolkit for investigating social cognition, we now propose, can be followed by an expansion into wider and deeply-related research questions, beyond (but including) that of social cognition narrowly construed.

Our social lives are populated by different kinds of cognitive and affective phenomena apart from figuring out other minds. They include acting and perceiving together, verbal and non-verbal engagement, experiences of (dis-)connection, relations in a group, joint meaning-making, intimacy, trust, secrecy, conflict, negotiation, asymmetric relations, material mediation of social interaction, collective action, contextual engagement with socio-cultural norms, etc. These phenomena are often characterized by a strong participation by the cognitive agent, in contrast with the spectatorial stance of social cognition (Reddy and Morris, 2004; De Jaegher and Di Paolo, 2007). We use the broader notion of embodied intersubjectivity to refer to this wider set of questions.

Forty-two contributions to this Research Topic explore several of these themes. They combine ideas and methods from psychology, neuroscience, philosophy of mind, phenomenology, psychiatry and psychotherapy, social science, and language studies. The number of contributions confirms our suspicions that there is a genuine interest in embodied intersubjectivity.

All of the contributions in some way or other move beyond traditional cognitivist perspectives. Here we can simply highlight some of the most interesting ways in which this happens. As already mentioned, there is a recent trend to investigate the dynamics of actual interactive encounters between people. Several empirical studies in this Research Topic continue further along this line. They look at interactive encounters using methods such as thermal imaging, interactive virtual environments, or 1/f noise analysis, or combine existing methods with novel theoretical starting points.

Other work looks at aspects of embodied social understanding which are pertinent even in the absence of ongoing interaction. These include the richness of body kinematics, affect regulation, and life-story analysis. A few contributions focus on how embodied and interactive perspectives impact on developmental research. They study real-life interactions between infants and their care-givers in various contexts (infant pick-up, book sharing, pointing, cooperation, and expressiveness during play in chimpanzees). Aspects of psychopathology are explored also from an embodied intersubjective angle, inspiring research on intra- and inter-personal emotion regulation, social affordances, personal biography, and therapeutic play, and their effects on somatic symptom disorders, autism, and schizophrenia.

Broadening the scope of relevant questions for embodied intersubjectivity inevitably means including research on language. Many of the contributions make headway on this matter, questioning the notion of the common ground, the role of conformity in social understanding, the processes involved in the activity of reading texts, and the links between conversational coordination and meaning-making. Others investigate the participatory nature of understanding narratives, and the role of organizational, temporal, and inter-affective aspects in language. Similar advances can be made in the area of connecting the cognitive and the social sciences. This is a very fruitful but still largely unexplored territory. A discussion is offered along Marxist lines concerning the interaction between categories of understanding and modes of social exchange and production. And the lessons of embodied/enactive approaches to intersubjectivity are summoned to contribute to understanding the phenomenological and social effects of solitary confinement.

Finally, some contributions elaborate theoretical and methodological implications and concepts, and in this way contribute to shaping the core of an embodied science of intersubjectivity. Methodological issues include whether dynamical systems concepts can bridge the multiple scales involved in social understanding, from the biological and neural to the personal, interactive and societal, how second person perspectives in cognitive science can help psychopathology research, and whether techniques used in theater can refine intuitions and theoretical concepts about interactive experience. Theoretical advances include radically embodied accounts of intersubjectivity that bring together conceptions from enactivism and ecological psychology, the notion of intersubjective time, and a socially embodied notion of the human self. Other discussions offer links between interpersonal interaction and phenomenal experience, between social normativity and conceptual abilities, or unearth the importance of opacity, i.e., the secret, silent or hidden aspects of personal experience, for understanding each other.

It is noteworthy, and especially satisfying, that many novel themes and questions emerged, several of them in some way related to personal meaning. To name a few: joy, secrecy, solitude, influence of capitalist mode of production on cognition, book sharing in infancy, the search for comprehensiveness and integrity in interacting, literature, and enactivism, ethics of care, shame in relation to interaction, and the interactive building blocks of culture and institutions.

Once again, we notice that the contributions to this Research Topic demonstrate the richness of enquiry and research work that is opened by the combination of novel methods and the bringing together of fields that traditionally work in isolation from each other. It also shows that criticisms of classical approaches as being sometimes too narrow are not just idle but point to genuinely new perspectives on concrete and everyday intersubjectivity that are opened to investigation.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

This work is supported by the Marie-Curie Initial Training Network, “TESIS: Towards an Embodied Science of InterSubjectivity” (FP7-PEOPLE-2010-ITN, 264828).

References

De Jaegher, H., and Di Paolo, E. (2007). Participatory sense-making: an enactive approach to social cognition. Phenomenol. Cogn. Sci. 6, 485–507. doi: 10.1007/s11097-007-9076-9

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Di Paolo, E. A., and De Jaegher, H. (2012). The interactive brain hypothesis. Front. Hum. Neurosci. 6:163. doi: 10.3389/fnhum.2012.00163

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Dumas, G., Nadel, J., Soussignan, R., Martinerie, J., and Garnero, L. (2010). Inter-brain synchronization during social interaction. PLoS ONE 5:e12166. doi: 10.1371/journal.pone.0012166

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Konvalinka, I., and Roepstorff, A. (2012). The two-brain approach: how can mutually interacting brains teach us something about social interaction? Front. Hum. Neurosci. 6:215. doi: 10.3389/fnhum.2012.00215

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Reddy, V., and Morris, P. (2004). Participants don't need theories: knowing minds in engagement. Theory Psychol. 14, 647–665. doi: 10.1177/0959354304046177

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Schilbach, L., Timmermans, B., Reddy, V., Costall, A., Bente, G., Schlicht, T., et al. (2013). Towards a second-person neuroscience. Behav. Brain Sci. 36, 393–462. doi: 10.1017/S0140525X12000660

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Van Overwalle, F. (2009). Social cognition and the brain: a meta-analysis. Hum. Brain Mapp. 30, 829–858. doi: 10.1002/hbm.20547

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Here are some of the articles posted in this Research Topic so far. If you follow the link, you'll be on page one of four (43 articles going back to the beginning of 2014).

Enactive account of pretend play and its application to therapy

Zuzanna Rucinska and Ellen Reijmers

Perspective: This paper informs therapeutic practices that use play, by providing a non-standard philosophical account of pretence: the Enactive Account of Pretend Play. The EAPP holds that pretend play activity need not invoke mental representational mechanisms; ...

Published on 02 March 2015
Front. Psychol. doi: 10.3389/fpsyg.2015.00175

 * * *

Embodied intersubjective engagement in mother–infant tactile communication: a cross-cultural study of Japanese and Scottish mother–infant behaviors during infant pick-up

Koichi Negayama, Jonathan T. Delafield-Butt, Keiko Momose, Konomi Ishijima, Noriko Kawahara, Erin J. Lux, Andrew Murphy and Konstantinos Kaliarntas

Original Research: This study examines the early development of cultural differences in a simple, embodied and intersubjective engagement between mothers putting down, picking up, and carrying their infants between Japan and Scotland. Eleven Japanese and 10 Scottish ...

Published on 27 February 2015
Front. Psychol. doi: 10.3389/fpsyg.2015.00066 

* * *

Assessing embodied interpersonal emotion regulation in somatic symptom disorders: a case study

Zeynep Okur Güney, Heribert Sattel, Daniela Cardone and Arcangelo Merla

Original Research: The aim of the present study was to examine the intra- and interpersonal emotion regulation of patients with somatic symptom disorders (SSD) during interactions with significant others (i.e. romantic partners). We presented two case couples for ... 

Published on 10 February 2015
Front. Psychol. doi: 10.3389/fpsyg.2015.00068

* * * 

Navigating beyond “here & now” affordances—on sensorimotor maturation and “false belief” performance

Maria Brincker

Perspective: How and when do we learn to understand other people’s perspectives and possibly divergent beliefs? This question has elicited much theoretical and empirical research. A puzzling finding has been that toddlers perform well on so-called implicit false ... 

Published on 15 December 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01433

* * *

 
 

Jointly structuring triadic spaces of meaning and action: book sharing from 3 months on

Nicole Rossmanith, Alan Costall, Andreas F. Reichelt, Beatriz López and Vasudevi Reddy

Original Research: This study explores the emergence of triadic interactions through the example of book sharing. As part of a naturalistic study, 10 infants were visited in their homes from 3-12 months. We report that (1) book sharing as a form of ... 

Published on 10 December 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01390

* * * 

Keep meaning in conversational coordination

Elena C. Cuffari

Perspective: Coordination is a widely employed term across recent quantitative and qualitative approaches to intersubjectivity, particularly approaches that give embodiment and enaction central explanatory roles. With a focus on linguistic and bodily coordination ... 

Published on 03 December 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01397

 * * *

Toward an expansion of an enactive ethics with the help of care ethics

Petr Urban

Opinion
Published on 27 November 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01354

* * *

Enacting a social ecology: radically embodied intersubjectivity

Marek McGann

Hypothesis & Theory: Embodied approaches to cognitive science frequently describe the mind as “world-involving”, indicating complementary and interdependent relationships between an agent and its environment. The precise nature of the environment is frequently left ... 

Published on 18 November 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01321

* * *

Quantifying long-range correlations and 1/f patterns in a minimal experiment of social interaction

Manuel G. Bedia, Miguel Aguilera, Tomás Gómez, David G. Larrode and Francisco Seron

Original ResearchIn recent years, researchers in social cognition have found the `perceptual crossing paradigm' to be both a theoretical and practical advance towards meeting particular challenges. This paradigm has been used to analyze the type of interactive ... 

Published on 12 November 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01281

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Why call bodily sense making “languaging”?

Giovanna Colombetti

General Commentary
Published on 07 November 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01286

* * *

Pooling the ground: understanding and coordination in collective sense making

Joanna Rączaszek-Leonardi, Agnieszka Dębska and Adam Sochanowicz

Hypothesis & Theory: Common ground is most often understood as the sum of mutually known beliefs, knowledge and suppositions among the participants in a conversation. It explains why participants do not mention things that should be obvious to both. In some accounts of ...

Published on 07 November 2014
Front. Psychol. doi: 10.3389/fpsyg.2014.01233

DAN ZAHAVI - Is the Self a Social Construct?

 

Dan Zahavi is a Danish philosopher and currently Professor of Philosophy at University of Copenhagen. Zahavi writes on phenomenology (especially the philosophy of Edmund Husserl) and philosophy of mind. He has written extensively on topics such as self, self-consciousness, intersubjectivity and social cognition. He is co-editor of the journal Phenomenology and the Cognitive Sciences.

Zahavi is the author of several books, including Self-Awareness and Alterity: A Phenomenological Investigation (1999), Husserl's Phenomenology (Cultural Memory in the Present) (2003), and the classic Subjectivity and Selfhood: Investigating the First-Person Perspective (2005). You can read selected papers here.

Is the self a social construct?

DAN ZAHAVI
University of Copenhagen, Denmark

Abstract:

There is a long tradition in philosophy for claiming that selfhood is socially constructed and self-experience intersubjectively mediated. On many accounts, we consequently have to distinguish between being conscious or sentient and being a self. The requirements that must be met in order to qualify for the latter are higher. My aim in the following is to challenge this form of social constructivism by arguing that an account of self which disregards the fundamental structures and features of our experiential life is a non-starter, and that a correct description and account of the experiential dimension must do justice to the first-person perspective and to the primitive form of self-referentiality, mineness or for-me-ness that it entails. I then consider and discuss various objections to this account, in particularly the view that an endorsement of such a minimal notion of self commits one to an outdated form of Cartesianism. In the final part of the paper, I argue that the self is so multifaceted a phenomenon that various complementary accounts must be integrated if we are to do justice to its complexity.

Author's Copy: Forthcoming in Inquiry

There is a long tradition in philosophy for claiming that selfhood is socially constructed and self-experience intersubjectively mediated. It is a view that has had many different voices. According to a widespread reading, Hegel argued that subjectivity is something that can only be achieved within a social context, within a community of minds, and that it has its ground in an intersubjective process of recognition rather than in some immediate form of self-familiarity. In the late 19th and early 20th Century related views were defended in the US by Royce and Mead. According to Royce, “Self-conscious functions are all of them, in their finite, human and primary aspect, social functions, due to habits of social intercourse”(Royce 1898, 196). Mead argued that the self is not something that exists first and then enters into relationship with others, rather it is better characterized as an eddy in the social current (Mead 1962, 182), and he explicitly defined self-consciousness as being a question of becoming “an object to one’s self in virtue of one’s social relations to other individuals”(Mead 1962, 172). Partly playing on the etymological roots of the term “subject”–one is always subject to or of something – Foucault has more recently claimed that individuals acquire their sense of autonomy inside contexts of domination and subordination. Forming subjects and subjecting them to authority were in his view two sides of the same coin. As he wrote at one point, “the subject that is constituted as a subject –that is ‘subjected’ – is one who obeys”(Foucault 1976, 112). On this reading, subjectivity and individuality are not rooted in some free and spontaneous interiority. Rather, we are dealing with categories produced in a system of social organization. By forcing us to think about ourselves in terms that might support moral categories such as guilt and responsibility, the system will be better able to control and manage us. An example found in Althusser illustrates this idea well. When a policeman calls out to someone in the street, “the hailed individual will turn round.”And as Althusser then continues, “By this mere one-hundred-and-eighty-degree physical conversion, he becomes a subject”(Althusser 1971, 174).

Without denying that there are significant differences between these various proposals, I think it is fair to say that they are all united in their rejection of the idea that subjectivity and selfhood – and for reasons that will become apparent in the following, I will be using both notions interchangeably –are something innate, automatic and spontaneous. On many accounts, we consequently have to distinguish between being conscious or sentient, and being a self. The requirements that must be met in order to qualify for the latter are higher. More precisely, being a self is an achievement rather than a given, and therefore also something that one can fail at. Selves are not born, but arise in a process of social experience and interchange. Indeed many would consider the self a construction, something more a matter of politics and culture, than of science and nature.

My aim in the following is not to dispute that there are important insights to be found in such claims. However, insofar as they are presented as accounts of the self tout court, rather than as accounts of certain dimensions or aspects of self, I find all of them unpersuasive. I think there is a basic yet crucial aspect of self that they all fail to consider let alone explain. To put it differently, I am opposed to the claim that the self is nothing but a social construct and in the following I will argue against this kind of social reductionism by outlining a more basic experiential notion of self that I consider a necessary precondition for any socially constructed self. This more basic notion is one with a venerable ancestry. It has been defended by various figures in the phenomenological tradition.

Read the whole article.

Traumatic Narcissism and the Traumatizing Narcissist

 

Below are some excerpts from Traumatic Narcissism: Relational Systems of Subjugation, by Daniel Shaw, a book that is completely revising the way I understand narcissism, in general, and the narcissistic wound, in particular.

I see a lot of traumatic narcissism in my clients, and until now I have not had a term for it. We all have seen books like Toxic Parents: Overcoming Their Hurtful Legacy and Reclaiming Your Life (Susan Forward), Children of the Self-Absorbed: A Grown-Up's Guide to Getting Over Narcissistic Parents (Nina Brown), or Trapped in the Mirror: Adult Children of Narcissists in their Struggle for Self (Golomb Elan). These are very useful books for our clients to read, but they do not offer much for the relationally-inclined, intersubjectively-focused psychoanalyst.

The great beauty of Shaw's book, for me, is that he approaches this topic from a relational perspective, which is aligned with my approach to therapy.

Narcissism can be understood as both traumatic and traumatizing:

• The developmental traumas that engender narcissism are transmitted intergenerationally
• The central trauma in the genesis of narcissism is chronic, insufficiently repaired failures on the part of caregivers to support the developing child's needs for recognition as a separate subject
• The chronic failures of recognition thwart the child's achievement of the capacity for intersubjective relatedness
• Most often, these chronic failures arise as a result of narcissistic disturbances in the parent
Pages 3-4

In his long suppressed, extraordinary final paper, "Confusion of Tongues" (Sandor Ferenczi 1933/1980), Ferenczi did much more than point to adult sexualization of children, rather than infantile sexuality and fantasy, as a cause of serious psychological damage the child carries into adulthood. Ferenczi went further, identifying the complex, cumulative emotional trauma the child who is neglected and/or abused experiences in the context of the developmental relationship. He went to describe how parents project their disavowed guilt (and shame) on to the child; and how resentful they were, no matter how well masked, of the child's dependence on them--because of their own disavowed wishes to be the focus of attention and care. He recognized that such parents dissociatively take advantage of  the child's instinctive willingness to "introject" the guilt and shame the parent disavows. The child, Ferenczi understood, does this by becoming self-blaming, self-loathing, and self-sacrificing. He becomes the caretaker of the parent, while dissociating the awareness of his own needs, along with his concomitant grief and rage about feeling abandoned and exploited.

Page 4

As with all forms of trauma, dissociation becomes a central survivor mode for the adult child of the traumatizing narcissism. Trauma theorists describe aspect of dissociation as the formation of the "protector/persecutor self" (Howell, 2005; Kalsched, 1996). ... The voice of the protector/persecutor says: "No. Do not believe in yourself, do not hope, do not dare. You'll only be hurt again." As the voice becomes more fearful of retraumatization, it becomes more laden with rejection and hostility, dissociatively identified with and mimicking the traumatizing narcissist caregiver: "You nothing, you loser! No one could or would ever love you, you're disgusting! Give up!"

Page 8

From here on, he spends several pages focused on how the child of narcissistic, traumatizing parents can turn their pain and wounding outward, rather than adopting the dissociative model presented above.

There is a different route taken by some children of traumatizing narcissists--involving externalization, rather than internalization, of the hostile projects of the narcissist parents. People in this group, the externalizers, might come to disdain needs altogether, and imagine that they themselves have no needs, that only others are weak and needy. This sort of person could become fixed in a subjective orientation, paving the way toward manic grandiosity and contempt for others, with a sense of entitlement and self-justification. The same cumulative traumatization to the sense of subjectivity as with the objectified child has taken place, but this child, rather than succumbing to a sense of helplessness and despairing of being able to feel recognized, instead develops as an adult into someone who arranges to wield the power to bestow, or not bestow, recognition upon others. ... Another way to think about this is to posit that the traumatized, thwarted subjective self of this child morphs into a protector self, which succeeds in preventing the internalization of shame and badness. Instead this super-defended self locates badness only in others--never in the self. Rather than persecute the self, this dissociated protector is quick to detect inferiority in others, and able to maintain the sense of superiority quite consistently.

Page 8

The patient who is labeled the deflated, thin-skinned pathological narcissist is usually someone who in development has suffered severe damage to their self-esteem system, and whose self-esteem regulation is therefore inconsistent and precarious, subject to the internal persecution of the split-off protector self. In my view, this person is more aptly deemed a sufferer of cumulative, developmental, post-traumatic stress. These patients are inhabited and often tormented by the ghosts of their traumatizers. 

Page 10

The overinflated narcissist is often someone much more like the original Narcissus of Ovid's Metamorphoses, as I understand the Narcissus myth: reveling in being wanted and adored by others, contemptuously deeming no one good enough; reinforcing his grandiose overvaluation of himself by sadistically negating the value and worth of others; and ultimately trapped and destroyed by his delusional obsession with what he perceives to be his own perfection. The narcissist in real life, a myth in his own mind, is so well defended against his developmental trauma, so skillful a disavower of the dependency and inadequacy that is so shameful to him, that he creates a delusional world in which he is a superior being in need of nothing he cannot provide for himself. To remain persuaded of his own perfection, he uses significant others whom he can subjugate. These spouses, siblings, children, or followers of the inflated narcissist strive anxiously to be what the narcissist wants them to be, for fear of being banished from his exalted presence. He is compelled to use those who depend on him to serve as hosts for his own disavowed and projected dependency, which for him signified profound inadequacy and is laden with shame and humiliation. To the extent that he succeeds in keeping inadequacy and dependency external, he can sustain in his internal world his delusions of shame-free, self-sufficient superiority.

Page 10-11

I am especially focusing on a particular type of the predominately overinflated, entitled, grandiose narcissist, and the way in which this person characteristically organizes relationships. I call this person the "traumatizing narcissist." In what I (Shaw, 2010) have previously termed "the pathological narcissist's relational system," I describe the narcissist who seeks hegemony for his subjectivity by weakening and suppressing the subjectivity of the other for the purpose of control and exploitation. The other is then left in grave doubt about the validity and even the reality of their own subjectivity. The sadistic, abusive aspect of narcissism stems from the belief, often held unconsciously, that the separate subjectivity of the other is a threat to the survival, literally and/or figuratively, of one's own subjectivity--and the other must therefore be captured and kept under control. 

Page 12

What is most characteristic of the traumatizing narcissist as I am defining him is his compelling need to suppress subjectivity in the other, so that the narcissist's subjectivity is always the exclusively important and only valid focus of any dyad or group. ... Unconsciously, he is using the other to identify with and internalize the disavowed, shameful dependency he projects onto others. In the case of a traumatizing narcissist parent, the child's subjectivity is attacked, suppressed, and shattered. In this situation, the developing child's ability to self-regulate and balance the innate narcissistic tendencies is not just unsupported, but actively derailed by the parent.

Page 12-13

 I'm sure that as I get deeper into the book, I will have more to share. Stay tuned.
   

George Atwood - The Abyss of Madness

[NOTE: I originally posted this in August of 2012. However, I am seeing clients who would fall into the definition Atwood uses for "madness."]

I am reading George Atwood's The Abyss of Madness (Psychoanalytic Inquiry Book Series) (2011) as part of an intersubjective, relational psychoanalytic study group I have been a part of for the last two and a half years. Aside from a few essays, this is is the first work I have read that is specifically Atwood's own thinking (most of the other books he had co-authored with Robert Stolorow).

Here is the description of the book from Amazon:

Despite the many ways in which the so-called psychoses can become manifest, they are ultimately human events arising out of human contexts. As such, they can be understood in an intersubjective manner, removing the stigmatizing boundary between madness and sanity. Utilizing the post-Cartesian psychoanalytic approach of phenomenological contextualism, as well as almost 50 years of clinical experience, George Atwood presents detailed case studies depicting individuals in crisis and the successes and failures that occurred in their treatment. Topics range from depression to schizophrenia, bipolar disorder to dreams, dissociative states to suicidality. Throughout is an emphasis on the underlying essence of humanity demonstrated in even the most extreme cases of psychological and emotional disturbance, and both the surprising highs and tragic lows of the search for the inner truth of a life – that of the analyst as well as the patient.

I very much like the way he conceptualizes these issues, even when I do not agree with his perspective on the mind. The way he talks about mental illness feels right in terms of how the client experiences it, and in the relational/intersubjective model, meeting the client in his or her own reality is essential.

When he speaks of madness in these passages, he is referring to psychosis and schizophrenia, or even bipolar disorder in its manic stage. These are not cases of simple depression, although there is certainly some similarity at a much lower intensity. And all these terms are things that he rejects as scientific defense mechanisms against our own fears of the abyss and what that means for our shared sense of being human.

It's worth bearing in mind that the psychoanalytic school refused to treat the "psychotics" for decades following Freud based on his assumption that they were not amenable to treatment. Harry Stack Sullivan, in the late 1920s, was one of the first psychoanalytically trained therapists to work with schizophrenics, and he did so based on his "problems with living" definition of mental illness. Sullivan was also one of the first psychoanalysts to focus on the "self system" as the outcome of relational patterns in the child's life (eventually giving rise to attachment theory). Atwood is definitely a lineage holder in the tradition Sullivan created that has been expanded upon by Stolorow, Donna Orange, and others.

Here a few quotes that I have highlighted in the text that I think are illustrative of his thinking.

Phenomenologically, going mad is a matter of the fragmentation of the soul, of a fall into nonbeing, of becoming subject to a sense of erasure and annihilation. The fall into the abyss of madness, when it occurs, is felt as something infinite and eternal. One falls away, limitlessly, from being itself,  into utter nonbeing.  (p. 40)

* * * *

Madness is not an illness, and it is not a disorder. Madness is the abyss. It is the experience of utter annihilation. Calling it a disease and distinguishing its forms, arranging its manifestations in carefully assembled lists and charts, creating scientific-sounding pseudo-explanations for it--all of these are intellectually indefensible, and I think they occur because of the terror. What is the terror I am speaking of? It is the terror of madness itself, which is the anxiety that one may fall into nonbeing.

The abyss lies on or just beyond the horizon of every person's world, and there is nothing more frightening. Even death does not hold a terror for us comparable to the one associated with the abyss. (p. 41)

He suggests that death offers a potential reunion with loved ones, or conversely, a release or relief from the sorrows and pains of our lives. We can rage against the dying of the light, or marvel at our capacity to contemplate our own demise, or even imagine the world without us.

But the descent into madness, into the abyss, offers no such relief.

It is the end of all possible responses and meanings, the erasure of a world in which there is anything coherent to respond to, the melting away of anyone to engage in a response. It is much more scary than death, and this proven by the fact that people in fear of annihilation--the terror of madness--so often commit suicide rather than continue with it. (p. 42)

* * * *

People often fall not because the bad happens, but rather because the good stops happening. Sanity is sustained by a network of validating, affirming connections that exist in a person's life: connections to other beings. If those connections fail, one falls. The beings on whom one relies include, obviously, other people, sometimes animals, often beings known only through memory and creative imagination. It some instances it is the connection to God that protects a person against madness. Strip any person of his or her sustaining links to others, and that person falls. No one is immune, because madness is a possibility of every human life. (p. 43)

* * * *

What a person in the grip of annihilation needs, above all else, is someone's understanding of the horror, which will include a human response assisting in the journey back to some sort of psychological survival. A person undergoing an experience of the total meltdown of the universe, when told that his or her suffering stems from a mental illness, will generally feel confused, invalidated, and undermined. Because there are no resources to fight against such a view, its power will have a petrifying effect on subjectivity and deepen the fall into the abyss. (p. 45)

Atwood contends that an objectified psychiatric diagnosis is the antithesis of what is needed - essentially mirroring and validation. He offers a thought experiment: Imagine a young man, maybe in his early 20s, who is in the midst of a fall into the abyss. This young man finds himself committed to an in-patient psych ward where he is given the diagnosis of a brain disease called schizophrenia.

The annihilating impact of such a view then becomes symbolized in the patient's unfolding experience that vicious, destructive voices are speaking to him over invisible wires and saying repeatedly that he should die. In this way a spiraling effect occurs, wherein the operation of the medical model further injures the already devastated patient, whose reactions to the new injuries in turn reconfirm the correctness of the diagnosis. (p. 45-46)

He prefers to be with the client in whatever space they inhabit, to show them that he is listening and trying to comprehend their experiences as much as he is able - and, above all else, that he is prepared to do whatever is necessary to help.

I have had clients in the past who I felt unable to help, because I was unable to be with them in their abyss, to extend my empathy into what I experiences as their delusional states. I failed them. Even as I sat with them and tried to understand what they were telling me, I did not understand that their delusions were their psychic organizing principles, were their symbolic truth of how the world has betrayed them.

Atwood, in the many case studies he presents, is revealed as someone who can feel into the annihilation his clients present him with, but he also acknowledges how challenging it is:

Working in the territory of annihilated souls is never easy. To really listen to someone, anyone, to hear the depth of what he or she may have felt, to work one's way into realms of experience never before perceived by anyone and therefore never articulated--all of this is as hard a task as one may undertake. (p. 51)

It is indeed. And it is also rewarding when the therapist can do so successfully and allow the client to feel heard and validated - maybe for the first tine in their lives.

I want to wrap up this post with a few more passages that deal with etiology. I posted some thoughts recently on a more relationally based diagnostic manual for counselors and therapists - Atwood conceptualizes cases in a way that fits with what I would like to see.

Those who feel they are not present, and who affirm the existence of machine that controls their minds and bodies, are often the products of profound enmeshment with their caregivers in childhood. An accommodation has taken place at a very young age in which the agenda of the caregiver--it can be the mother, the father, or both--becomes the supreme principle defining the child's developing sense of personal identity. The experience of the child as an independent person in his or her own right is nullified, so that they child the parents wish for can be brought into being. Very often thee are no outward signs of anything amiss, as family life unfolds in a seeming harmony. Somewhere along the way, however , the false self begins to crumble, and a sense of the degree to which the child has been absent from life arises. This emerging sense of never having been there, of having been controlled and regulated by outside forces, is so unstable and fragmentary that it is given concrete form. What is seen from the viewpoint of others as a delusion then begins to crystallize, for example in the image of an influencing machine (Tausk, 1917; Orange et al., 1997, chap. 4). Within the world of the child, now perhaps chronologically an adult, the so-called delusion is a carrier of truth that has up until then been entirely hidden and erased. What looks like a breakdown into psychosis and delusion thus may represent an attempted breakthrough, but the inchoate "I" does require an understanding and responsive "Thou" in order to have a chance to consolidate itself. (p. 60-61)

 That last sentence is the essence of the relational model - we are relational beings, the damage to our sense of self that we experience is nearly always relational, and if there is to be healing of that damage, that too much be relational - it requires mirroring, validation, and the sense of human connection that is vital to sanity for all of us.

This is an interesting article that analyzes, with a qualitative model, the intersubjective aspects of schizophrenia. This may be too geeky for some readers, but I am finding more psychosis in my counseling work, and this helps me understand better what the client is experiencing. 

Here is an explanation of the paper's agenda:

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

It's worth the read to get through this if you are at all interested in how psychosis affects the mind, and especially if someone you know or love has to deal with the burden of psychosis.

Intersubjectivity in schizophrenia: Life story analysis of three cases

Leonor Irarrázaval [1] and Dariela Sharim [2]

1. Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Santiago, Chile
2. Escuela de Psicología, Facultad de Ciencias Sociales, Pontificia Universidad Católica de Chile, Santiago, Chile

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

Introduction

Pathological experiences are usually described as phenomena that are divorced from the life context in which they are manifested. Nevertheless, in the field of phenomenological psychopathology, symptoms have traditionally been considered from a more comprehensive perspective: they are embedded in the person’s life thus their contents and meanings can only be understood within the context of that life. In themselves “unhistorical,” symptoms become connected meaningfully only within the comprehensive picture of the patient’s life as a whole (Jaspers, 1997).

An even stronger argument could be made to the effect that “no mental illness can be diagnosed, described, or explained without taking account of the patients’ subjectivity and their interpersonal relationships” (Fuchs, 2012, p. 342). It is clear that psychopathological manifestations cannot simply be reduced to the workings of the nervous system (Fuchs, 2011). For that reason, the recommendation here would be not to establish linear or “cause/effect” relationships, but to approach mental illnesses with the notion of a “circular” mode of causality, regarding their emergence from subjective, neural, social, and environmental influences continuously interacting with each other (Fuchs, 2012).

Contemporary psychopathological phenomenology regards schizophrenia as a paradigmatic disturbance of embodiment and intersubjectivity (Dörr, 1970, 1997, 2005, 2011; Blankenburg, 2001, 2012; Fuchs, 2001, 2005, 2010a; Sass and Parnas, 2003; Stanghellini, 2004, 2009, 2011). From this approach, it seems appropriate to use methods that attempt to characterize not only the patients’ symptomatic disturbances but also the interpersonal processes involved, broadening the scope of exploration to areas not taken into account in the criteriological manuals of diagnostic systems Diagnostic Statistical Manual of Mental Disorders (DSM) and International Classification of Deseases (ICD) (Fuchs, 2010b).

This paper presents the life story analysis of three cases that form part of the corresponding author’s doctoral dissertation entitled “Study of disorders of the pre-reflexive self and of the narratives of first admitted patients with schizophrenia” (unpublished), covering a total of 15 patients with schizophrenia during their first psychiatric hospitalization.

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

Here, “life-world” refers to the person’s subjectively experienced world, which emerges in the process of conceiving one’s self and the others through a history of social interactions (Husserl, 1970; Schutz and Luckmann, 1973; Varela, 1990; Varela et al., 1991; Maturana and Varela, 1996).

Materials and Methods

Study Design

The study was developed within the qualitative paradigm, it being an explorative–descriptive type of study. This type of studies proceeds with inductive logic: in other words, both hypotheses and analysis categories are developed as the study progresses, and emerge from the data itself (Danhke, 1989 quoted in Hernández et al., 2003).

The so-called “critical case sampling” criteria was used, where the interest in an in-depth approach to the phenomena means working with few cases, with representativeness not being of key importance for these purposes. Thus, the significance and understanding emerged by qualitative inquiry have more to do with the richness of the cases chosen and also with the observational and analytical abilities of the researcher, rather than with size of the sample (Patton, 1990; Schwartz and Jacobs, 1996; Creswell, 1998).

Participants

The broad research covered a total of 15 patients with schizophrenia during their first psychiatric hospitalization. All of them were males, aged between 18 and 25. Additional inclusion criteria were the following: (1) accessibility to the sample, (2) homogenous sample (Halbreich and Kahn, 2003), and (3) earlier first onset and higher risk of developing schizophrenia in men (Aleman et al., 2003).

The three cases were selected due to the variety of subtypes to illustrate the interpersonal processes involved in schizophrenia, taking the intersubjective dimension of the patients’ life stories into consideration. Cases 1, 2, and 3, as they appear in the paper, correspond to patients with diagnoses of disorganized-type, paranoid-type, and catatonic-type schizophrenia, respectively.

Instruments

In-depth Interviews

In-depth interviews were used to gather qualitative data from the first encounter with the patients and from their life stories. These interviews had open questions aimed at allowing for a natural manifestation of the patients’ accounts. For the first encounter, the recommendations on interviews for the phenomenological diagnosis of schizophrenia were taken into account (Dörr, 2002), and clinical biographical focus criteria were used to perform the life story interviews (Sharim, 2005).

Positive and Negative Syndrome Scale

The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) is a rating scale used for measuring symptom severity of patients with schizophrenia. The name refers to the two types of symptoms: positive, which refers to an excess or distortion of normal functions (e.g., hallucinations and delusions), and negative, which represents a diminution or loss of normal functions.

The Examination of Anomalous Self-Experience

The Examination of Anomalous Self-Experience (EASE; Parnas et al., 2005) is a semi-structured interview for the phenomenological examination of disorders of the pre-reflexive self, postulated as early markers or basic phenotype of the schizophrenic spectrum (Raballo et al., 2011). The EASE explores a variety of anomalous self-experiences, which typically precede the onset of positive symptoms and which also often underlie negative and disorganized symptoms (Parnas and Handest, 2003).

Procedures

Data gathering was performed by means of semi-structured interviews, which are characterized by the use of eminently “open” research questions. Less structured methods allow for the emergence of ideographic descriptions, personal beliefs and meanings, focusing on “how” the psychological processes occur (Barbour, 2000).

Five encounters with the patients were carried out. These encounters were coordinated throughout the three following phases:

Phase I: A first encounter to record the patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episode (30–45 min interview carried out 1–2 weeks after hospitalization), following the confirmation of the diagnosis of schizophrenia in accordance with expert judgment and the standard diagnostic criteria of DSM-IV-R (American Psychiatric Association, 2003) and ICD-10 (OrganizaciónMundial de la Salud, 2003).

Phase II: Two subsequent encounters to carry out the EASE (Parnas et al., 2005; 30–45 min per interview carried out 1 month after hospitalization), when patients did not score with “positive” symptomatology on the PANSS (Kay et al., 1987).

Note: The results of Phase II of the broad research have not been included in this paper. The results from the EASE exploration will be published in a complementary paper focused on basic self-disorders entitled “The lived body in schizophrenia” (in preparation).

Phase III: Finally, two further encounters were held to perform the life story interviews (30–45 min per interview carried out 1–2 months after hospitalization). The first encounter started with the open instruction “tell me about your self,” “tell me about your life,” while the second one was focused mainly on the patients’ significant social interactions and personal meanings, also including their first image in life, their early dreams (hopes), their self-definition, and their expectations about the future.

All the interviews were recorded on video and fully transcribed for subsequent analysis. Extracts of the patients’ accounts were kept literally in quotes.

Analysis

First Encounter (Phase I)

The patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episodes were summarized in corresponding descriptions containing the essential structure of the transcripts, which were obtained with the “Descriptive Phenomenological Method in Psychology” (Giorgi, 2009), by following five steps: (1) the researcher reads the entire transcript in order to gain an overall sense, (2) the same transcript is then read more slowly, and underlined every time a transition in meaning is perceived, providing a series of units constituting meaning, (3) the researcher then eliminates redundancies and clarifies the meaning of the units, connecting them together to obtain a sense of the whole, (4) the arising units are expressed essentially in the language of the subject, revealing the essence of the situation for him, and finally, (5) there is the summarizing and integrating of the achieved understanding in a description with the essential structure of the transcript.

Life Story Interviews (Phase III)

The criteria of the clinical biographical focus were considered in the life story analysis, which are part of the so-called “clinical human sciences” paradigm (Legrand, 1993; Sharim, 2005, 2011). This approach stresses the life story method, in which the clinical dimension is constantly present, working primordially on singularity: case-by-case, story-by-story.

At the same time, the examination of singularity and heterogeneity of individual situations allows the progressive appearance of common processes that structure behavior and organize these situations (Sharim, 2005, 2011; Cornejo et al., 2008). This method highlights the role of the subject in recounting his life story, giving the possibility to analyze the reciprocal relationship between the subject’s determination by his history and his potential to create his own existence (De Gaulejac, 1999; De Gaulejac et al., 2005).

The in-depth analysis of the life stories was developed under a course guided by the co-author of this paper. The course was called “Hermeneutic analysis of biographical material for the study of patients with schizophrenia” and took place during one academic semester at the Catholic University of Chile. The analysis focused on the personal meanings (Fuchs and De Jaegher, 2009) by following the patients’ history of significant social interactions.

Therefore, the transcripts were analyzed by peer researchers (corresponding author and co-author of this paper) both clinical psychologists with a specialty in psychotherapy. To avoid bias each researcher previously made a separate analysis and then met for the co-analysis, ensuring with this procedure the validity of the qualitative research (Maxwell, 1996; Morrow, 2005; Fischer, 2009).

Firstly, an individual (case-by-case) in-depth analysis of each narration using a hermeneutic approach was carried out. In this analysis each life story was re-constructed, carrying out a thematic and chronological ordering, which enabled the identification of “biographical milestones,” as well as the analytical axes in each life story. Second, a cross-sectional analysis was carried out contemplating the stories all together, revealing the differences, similarities, and shared structural dimensions.

Ethical Issues

The broad research, covering 15 patients with schizophrenia during their first psychiatric hospitalization, was regarded as entailing no physical, psychological, or social risks for the subjects involved, based on the Declaration of Helsinki principles, the Council for International Organizations of Medical Sciences (CIOMS) 1992 International Ethical Guidelines for Biomedical Research Involving Human Subjects, and the 1996 International Conference on Harmonisation (ICH) Good Clinical Practice guidelines, by the following Ethics Committees: (1) Research into Human Beings Ethics Committee of the University of Chile’s Medical Faculty, dated January 19, 2011. (2) Ethics Committee Research of the Psychiatric Hospital, dated August 2, 2012. (3) Ethics Committee Research of the North Metropolitan Health Service (Santiago, Chile), dated August 16, 2012.

The Ethics Committees also approved the patients’ and their tutors’ (legal representatives) consent documents. In this regard, the following ethical aspects were taken into account: (1) consent was informed and obtained from the patients’ tutors by the attending doctor at Phase I of the study, considering that as a patient affected by an acute episode of schizophrenia, his competence or capacity is diminished and he must be authorized to participate. (2) Consent was obtained directly from the patients at Phase II of the study. (3) Pseudonyms were employed to protect the identity of the patients and ensure confidentiality (internal codes were used for each patient to replace their original names).

Note: Careful attention was paid in this paper to the protection of the patients’ anonymity. Identifying information such as dates, locations, hospital numbers, etc., was avoided.

Results

Individual Analysis (Case by Case)

Case 1

Santiago (Santi) is an 18-year-old patient, diagnosed with disorganized-type schizophrenia. He has completed 8 years of basic school education. His father died of cancer 1 month before his hospitalization: until then, he lived with him and his two brothers. He is the middle brother. The patient’s mother left home when he was 12 years old.

First encounter. A first interview was carried out after 2 weeks of hospitalization. In this encounter, the patient indicates that although he considers himself to be a “normal” person, begins to recognize a “repetitive failure.” It is primarily the mediating process of thinking that has become the main impediment in this case.

The patient indicates that he hears voices, which are as if his own thoughts were repeated inside his head, like an echo, “as if I was reading them aloud but with my mouth closed.” Most of the voices repeat meaningless things that he does not understand. He also hears voices on the radio, repeating what he is thinking: these are voices of unknown people who seem to be talking to him. Additionally, it sometimes seems to him that some television personalities repeatedly say things to him, all sorts of non-sense. He does not know how or why they do.

There are periods in which the “repetitive failure” intensifies, to the extent that it prevents him leaving home, and that only by going to bed to sleep is he able to take a break from these thoughts. This has made it difficult for him to progress with his studies or concentrate. He feels that this situation is annoying for him and is harmful because he cannot live a normal life.

At first, the patient figured it was sort of a game, playing with the voices and thoughts, but he could not control it, he could not stop it, he kept on playing. This was sometimes unbearable for him, and has even made him want to hang himself.

Biographical milestones. The life story interviews were carried out after 2 months of hospitalization. The patient was receiving the usual pharmacological treatment and had recently completed 12 electroconvulsive therapy sessions.

“My mum left me when I was 12”

Santi begins his account by indicating that he has had a hard life. He refers to his parents’ divorce, and particularly to when his mother left him alone with his brothers when he was 12. His mother moved away from the city and got married again. “It was very hard, when she wasn’t there and we lacked a mother’s love.”

In addition to being angry with his mother when she left home, Santi also points out that he did not get on with her as a child. He remembers that she used to get very annoyed with him when he and his father sometimes made fun of her.

The mother returned after 2 years for her children. Santi’s brothers agreed to go with her, but he preferred to remain with his father. At the age of 14, he was living alone with his father. However, the brothers returned 2 years later, when he was 16, due to the serious situation with the mother’s new husband, who beat them.

Santi states that he got on well with his brothers; they had an affectionate relationship, one of friends, between them. They helped each other out and shared the housework between them.

“I died in high school”

Santi acknowledges that a significant change took place in his life at school. As a young child, he was a very good pupil and wanted to study medicine, but at the age of 12 he lost interest in his studies, skipped school, and began taking drugs. He had to repeat the last school year twice due to absenteeism. He liked the typical tools of the medical trade and wanted to have a stethoscope. “Now that I have them here (at the psychiatric hospital), I ask myself, why can’t I, if everyone else can?”

He stopped taking drugs at the beginning of this year and returned to his studies. He wanted to study accountancy to earn money. He had recently started the first year of high school when he was hospitalized.

“My dad passed away recently”

Santi states that his first memory is one of being with his family, when he was 7. It is a memory of the time when they were still living with their mother. He recalls it was his father who took them to a pretty square at the center of the city. “Nice memories, everything was nice with my dad.”

The father worked in the public sector and had taken early retirement, the reason for which is unknown. He did not remarry or have a relationship with another woman. Santi has a very positive image of him. He describes him as hard worker, a good father and who liked to go out and play ball with him and his brothers.

Santi displays an empathetic attitude toward his father, even a certain loyalty, which is made clear when he recounts the time when his mother left home, and later when his brothers left. In fact, he decided to stay alone with his father, despite the pain caused by the separation from his mother and brothers. “My dad went through an extremely painful time, to put it one way, he didn’t show it but, inside, he was feeling bad.”

The father passed away 3 months ago, from cancer, at the age of 65. He became ill a month before dying, and had immediately told his sons of his disease, so they were aware of how much longer the doctor had given him. The father was hospitalized at the time of his death.

Santi recognizes that he was very attached to his father, he states that “even too much.” He realizes that he still has not gotten over the death of his father, “because of my illness, I still have not gotten over it. I haven’t realized what it all really means.”

“I see the future as nothing”

Since the last 4 years, Santi has been becoming more and more distanced from the world, to the point where he is extremely isolated. He has no friends, does not study or work, takes no part in social activities and has not embarked on any romantic relationship.

During the week, he helped with some household chores, such as making lunch. Nor did he do anything special during the weekend, except go out to the square with his brother. He spent a lot of time in his room playing on his PlayStation. “I see the future as nothing, the way I’m going. Not doing anything, not studying, because where will I get like this? It’s looking bad, isn’t it? I’m worried.”

Life story analysis. The patient took part in the interviews without any problems. He appeared interested in obtaining more information on his state of health and motivated to seek help to secure a speedy discharge. He interrupted the interviews on a number of occasions to ask what his illness was, if it was very serious and when his attending doctor would discharge him. Generally, he appeared constantly concerned about his state and anxious to put an end to his confinement.

His life story contains a series of events that could be regarded as stressful. It is certainly possible to establish a connection between the death of his father (i.e., the patient’s state of grief) and the emergence of the first acute episode, and also to identify his mother’s leaving home as the crucial biographical milestone in the development of the prodromal stage of schizophrenia. Somehow, the sense of abandonment in the world has come to dominate the patient’s life.

The scale of the emotional impact of the recent loss of a father is obvious: nevertheless, the patient at no time displays any signs of sadness and does not cry. Instead of a spontaneous emotional expression, he rationally discerns the seriousness of the situation and like a “witness” he testifies the tremendous impact this must have on his life.

He manifested an initial perplexity, conveyed with a degree of humor, in light of the apparent oddness and incomprehensibility of the account of his anomalous experiences (“the repetitive failure”). Nevertheless, although he recounts sad events in his life, any actual sadness can only be assumed. To put it one way, it is possible to “intuit” the patient’s suffering, through the loneliness, abandonment and lack of support in his life, rather than by means of an explicitly emotional manifestation on his part.

The patient notices the paradoxical situation involved (of being hospitalized) when he states that he regards himself as a “normal” person, except for his “repetitive failure.” Far from merely being a game, as he previously regarded it, it is now given the name of schizophrenia, a diagnosis that defines him as a seriously ill patient and justifies his compulsory commitment to a hospital. This has led him to realize that what is happening to him is not socially acceptable, and is thus regarded as more serious in his own judgment.

Case 2

Angel is a 22-year-old patient, diagnosed with paranoid-type schizophrenia. He has 11 years of basic school education and lives with his parents and the eldest of his three sisters. He is the youngest of the siblings and the only brother. His family are evangelical Christians.

First encounter. A first encounter was carried out a week into his hospitalization. The patient has not been able to find a convincing explanation for the fear he feels, which he recognizes as his major impediment. He thinks he could be delivered over to the Tribulation – the Tribulation is a biblical time of pain.

About 3 months ago he began to feel persecuted by people. His house was the only place he felt safe, but for a few weeks now he has even begun to feel unsafe at home. The idea that somebody can hurt him comes from the fear he feels and he thinks that the worst thing would be that somebody kills him somehow, like stabbing him, for example. This fear is a distressing feeling, of wishing to escape, when he suddenly feels that something bad is going to happen to him.

He is quite concerned about his problem, and thinks a lot about it, and how to solve it. He wants to find a way to overcome the fear. He would like to find a “clear and precise” answer to what he should do, how he should live and how to face up to his fear. He wishes that the bible could tell him what to do in the Tribulation, “if I was in that time, that it told me in light of this fear to do this or that, to face up to it, don’t be afraid, I’ll be with you.”

Biographical milestones. The life story interviews were carried out 1 month into the patient’s hospitalization. He was receiving usual pharmacological treatment and his suitability for electroconvulsive therapy was being assessed.

“When I was a kid I went to school”

Angel woke up one night and found himself alone at home: it was very dark and he started crying. This is the earliest image that he recalls from his childhood. He also remembers that he would sometimes run up the stairs because he thought that someone, “perhaps the bogeyman,” was after him.

He remarks that his grades were not great but things went well for him at school. During his childhood, he felt good because he went out to play and climb trees. He also liked to fix televisions and take apart toy cars. He stresses the fact that he was more outgoing and playful as a child.

His family was always good to him, and he notes that he had a happy childhood. He was closest to his mother, as she stayed at home and was very attentive and loving toward him. His mother was of good character, and only punished him on a couple of occasions, “because once I hit my sister with a hammer, when I was playing, and my mum punished me, she gave me a slap on the behind.”

“My sisters were very critical of me”

Angel has three older sisters. He has had a difficult relationship with them, and particularly with the eldest. He points out that his sisters criticized him a great deal and made fun of him. Therefore, even as a child, he took great care to say the right thing, so as not to make a fool of himself and feel embarrassed.

He was not only concerned to ensure that he said the right thing, but also with his personal appearance. He was very sensitive about the comments his sisters made about him. He states that he was very shy as a child, and when he was embarrassed by something he would run away and did not want to come back.

“Then I went to high school”

At high school, Angel was unable to make friends. He notes that he changed, became less playful, less “chatty” and more reclusive. He did not play ball so much or join in with classmates as often.

He also comments that he found it difficult to appear in front of his classmates, and skipped school when he had to give a talk to the class on a subject. This got worse when he started to suffer from acne, which made him feel that people were looking at him too much and a little persecuted.

It was because of the acne that Angel began to skip school, until he stopped going completely and became totally isolated. “By this point, the acne wasn’t as bad, but it was the fact I missed school, I skipped class a lot, I was embarrassed that I skipped school so much, and that’s why I stopped studying.”

“Then I went out to work. That’s when it all went wrong”

Angel does not think that his acne is any better, but somehow he learned to come to terms with this concern. He has spent a lot of time at home, in his room playing on his PlayStation. This is what he has mostly done over the last 4 years, as he admits. “I didn’t see anyone except for my family, not friends, because it’s a bit solitary on the PlayStation, you get closed in on yourself when you’re on it.”

After 4 years, Angel went out to work. He notes that it is when everything went wrong. He had spent a lot of time at home, without going out. He notes that he was perhaps unprepared to go out and experience life like that all of a sudden. It was then that he began to feel that people were after him.

“Now, as a person”

In adolescence, Angel wanted to be an air force pilot but he could not apply because he did not finish his studies and was under the required height – “it came as quite a blow, but I was still interested in mechanics.”

Angel does not have a clear vision of what the future holds, principally because he has not overcome the fear of being harmed and the thought that “somebody” will kill him, which is his most serious affliction. Nevertheless, he indicates that, if he can overcome his fear, he would like to work and study mechanics and electronics, which have been interests of his since childhood.

Life story analysis. The patient was very willing to take part in the interviews, although he generally appeared tired and dispirited. He seemed not to have much to say, or not to be ready to recount his story. He is of a religious disposition and a frequent reader of the Bible where, above all, he hoped to find an explanation for the problem affecting him: his fear.

His account is mainly based around the fear of being harmed, which is the subject of his delusion. He even appears, in a way, excited when talking about the problem of his fear and about the different explanations he uses to understand what is happening to him. Aside from this core problem afflicting him, his account barely touched on other aspects of his life, and he appeared to become dispirited, tired, and uninterested when moving away from the subject of his delusion.

He seems concerned that he is unable to find certainty in things, above all with regard to explaining his fear. He feels prey to a fear that is completely restrictive, and is unable to find a satisfactory explanation that would allow him to understand what is happening to him or to give a completely convincing response to overcome the situation. He is aware of the extent of the fear and the significant limitations it causes in his life, and of the lack of any clear orientation as to how to overcome it.

The patient conveys a feeling of “ontological” uncertainty or insecurity. From an early age in his life, the world (and others) acquired a sense of unreliability or threat. Shame and fear of ridicule are the predominant emotional aspects of his experience in childhood. Somehow, later on in adolescence these emotions led to the fear of persecution. Persecution progressively became a fear of being hurt until it reached the extreme point of a fear that he would be killed, which manifested itself in the first acute episode.

Case 3

Salvador (Salva) is a 25-year-old patient, diagnosed with catatonic-type schizophrenia. He has completed 12 years of compulsory school education and lives with his father and older brother. His parents divorced 2 years ago.

First encounter. The first interview was carried out when the patient had been hospitalized for close to 2 weeks. He explains that 2 years ago started with an episode of mental illness: “I was getting cramps in the back of my brain.” It was because of the confusion these cramps caused in his brain that he went to the psychiatrist. Then, he was diagnosed with depression and treated with medication for a year but the problem persisted.

He feels mental pressures, and indicates it is as if they squeeze his brain. His thoughts are jumbled up, all messed up with ideas. Reality gets distorted for him as well, as if he were in a constant dream. In addition, he has felt someone possessing his body and explains it as “demonic possession.” He thinks that spirits get in when someone is depressed. It is something he cannot control, something unpredictable, imminent.

The patient is worried about the state of his mental health. It worries him to “live like this,” and he feels a deep-seated desperation. He does not want to do anything and feels depressed, downcast, dispirited, and powerless. Before he was hospitalized, he wanted to committed suicide by jumping off a hill due to the desperation.

Biographical milestones. When the life story interviews were carried out, the patient had been hospitalized for a month and a half. He was receiving the usual pharmacological treatment.

“My interest in religion began at the age of 8”

Salva completed his primary education at a Christian school. He liked the religious part of school because religion was taught in a fun way. When he was a child, he used to go to church with his family. “I liked the teachings about love, love for one another, love for one’s neighbor.”

He points out that he was a very good student and got very good grades. He wanted to be a vet when he was a child, because he liked animals. He describes himself as a gentle, playful, brotherly, sweet boy.

“They moved me to a worldly high school”

The change of school had a negative impact on Salva. His performance suffered, and he went from being an outstanding student to being just an average one. He notes that students at the new school were treated more coldly.

He had wanted to be a vet since childhood but he could not go to university, as he did not pass the entrance exams. He therefore chose to study architectural drawing at a college, but did not manage to complete his first year there.

“My mum was sweet to me when she was Evangelical”

Salva had a good relationship with his mother as a child. He points out that his mother was very loving toward him whilst she was Evangelical. Later, however, for reasons unknown to him, she distanced herself from church. Their relationship deteriorated when he was a teenager.

He got on badly with his mother because, he explains, of their very different characters. His mother ill-treated him and frequently insulted him. This made him feel powerless. “She was really aggressive, and punished and hit me for anything. She used to insult me in all kinds of ways, she called me mentally ill.”

His mother also fought with his father and brother. She drank, and when she did so she became more violent.

“I went through a lot in 2010”

Salva states that he had his first episode of “mental illness” 2 years ago, and has not been able to work or study since then. “I did nothing at home, just playing games on the computer; I’d play on it, football games and PlayStation. I spent a load of time doing that.”

It was in this same year that his mother left home and his father fell ill with diabetes. His brother had had a heart attack at the end of the previous year.

His mother left home to live with a new partner, saying she wanted her independence. At first he missed her, but was also angry. He did not want to see her or be with her after she left.

Salva continued to live with his father and brother. He feels very attached to them, and is concerned about their health. He feels he has a really great father, because he has had to play a double role. He gets on well with his brother too, who he regards as a second father.

“It’s great at church, they treat me really well”

Salva’s current friends are evangelicals and he joins them at church. He likes going to the church because there he got to know beautiful people and had a much closer relationship with God. “I like being in communion with God, praying, singing, that’s how I look for protection.”

He has had four episodes of “demonic possessions,” all of which happened at church. It was at church where he was told that his bodily experiences were “possessions” and that they are somehow “normal.” However, the treatment he was given there was unsuccessful. They carried out “deliverances,” which are a way of getting the devil out the body with prayer.

At the moment, Salva does not know why these episodes have happened to him, or whether they are due to an illness, and has not even talked much about the matter with his attending doctor.

“In the future, I want to study massage therapy”

Over the course of the last 7 years, Salva worked on and off in a number of fields. He took jobs as a shelf stacker in a supermarket, a cleaner at a cinema and a shop assistant. His last job was 2 years ago selling fragrances in a street market.

He has remained socially isolated over the last 2 years, only keeping in touch with his evangelical friends at church sporadically. “I’ve found it difficult to relate to people in recent years. I haven’t worked much or had much of a social life. I’ve been isolated.”

In the future he would like to have children, a wife and work giving massages, although he realizes that he remains scared about his mental state, that he feels vulnerable.

Life story analysis. The patient took part in the interviews willingly, although he did appear very tired and sleepy (he was constantly yawning). The disordered thoughts persist, as do his low spirits, mental pressures and the uncertainty in the face of possible new “possessions.” He talks about himself and his life quite candidly and seems naïve, as if recounted by a small child. He speaks calmly, slowly, with little verve. It is a story with few elements told at a basic level of articulation.

He is very religious, a habitual reader of the Bible and a regular churchgoer. Now, although the episodes were “demonic possessions,” fear does not appear to be the predominant or explicit emotion: it is rather the loss of control of his bodily experiences and the unpredictable nature of these episodes that make the patient desperate. In other words, his desperation is due to his inability to once again feel normal or healthy.

He left school 7 years ago and has not developed a specific plan to carry out his life. Although he wishes to have a “normal” life, his life project faces a vacuum. However, the lack of a plan does not seem to concern him at all. Instead, what most worries the patient at present is the state of his mental health, that is, the anomalous bodily experiences he is not able to control.

It is possible to make a connection between the emergence of the first acute episode and a series of stressful events that occurred in the patient’s life at that time: his mother left home, his father fell ill with diabetes and his brother had heart problems, all in the same year. Although, the negative impact of the change in high school and the deterioration of the relationship with his mother in his adolescence are the crucial biographical milestones identified in the development prodromal stage of schizophrenia.

Besides, what the patient explains as “spirits getting into” does not seem to correspond to a typically clinical depression (as it was diagnosed initially), but rather to a severe “passivity” of his own existence, which finds concrete form in his disembodied experiences.

Cross-Sectional Analysis

The cross-sectional analysis shows that a severe disorder of intersubjectivity starts developing in early adolescence. Beginning at an early stage, the patients progressively distance themselves from the social world. This distancing becomes a structural element, a key part in the prodromal stage of schizophrenia.

It is not an active deliberate distancing, but rather an overall difficulty that hampers the living of a normal life. It implies a progressive “passiveness” of the patients’ own existence, which manifests itself not only in the disturbances of self-experience and body alienations of the acute phases, but also in the patients’ radical withdrawal from the social world.

For several years, the patients have not worked or studied, have had no social life, and have stayed shut in at home watching television or playing on their PlayStation for hours at a time. Here, it is important to notice that the acute episode occurred at a time when they were planning to return to their studies or the world of work after a number of years of extreme isolation.

It is possible to make a connection between the prodromal stages of schizophrenia and several stressful events that occurred in the patients’ lives. It is also possible to follow a continuity in the experience of vulnerability regarding the main personal meaning configured early in life: the feeling of abandonment, the fear of ridicule and the feeling of powerlessness, corresponding to Cases 1, 2, and 3, respectively.

Nevertheless, the patients’ withdrawal from the social world is what eventually leads to the manifestation of their psychosis. Somehow, in their attempts to returning to intersubjectivity, all of a sudden the patients confront themselves with their own “vulnerability” of being in the world.

Although they have some ideas about what to do in the future, the patients are insufficiently prepared, and lack a specific plan to implement them properly. Their life project faces a vacuum. This is what makes their condition so severe: there is an interruption in the patients’ normal unfolding of life.

The patients do have a concept of what a “normal life” should be (basically, to study, to have a job, to marry, and to have a family), but they do not seem to possess the factual grounding needed to deal with the world, as if they were lacking the implicit “know how” to carry out the normal life they wish to live.

It should be noted that the patients’ life stories feature a series of healthy elements or personal qualities that reflect a certain nobility of character: sensitivity, authenticity, naivety, empathy, and innocence. There does not appear to be any secondary gain associated with the symptoms.

Discussion

Key Findings

In acute phases of schizophrenia, patients’ accounts concentrate on (or are limited to) the disturbances of self-experience or body alienations. In other words, patients’ accounts lie outside the time-space dimension of the social context and exclude personal history. Body alienation appears to be the way in which the de-subjectivized accounts find concrete form (or are materialized).

The assessment of the life stories complements the symptomatic descriptions embedding them in the patients’ life-worlds, thus incorporating a social horizon. In this way, the dimension of intersubjectivity is illustrated in the patients’ history of significant social interactions, discovering the interpersonal elements to integrate in psychotherapeutic and prevention models.

The articulation of the patients’ life stories allow to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence. Thus, the spatiotemporal dimension of the personal history allows the understandability of the interpersonal processes involved in schizophrenia from a broader perspective.

From the individual analysis of the life stories, it is possible to identify the patients’ biographical milestones, the personal meanings involved in their significant social interactions, and also continuity in their experience of vulnerability of being in the world, which are useful elements to consider for psychotherapeutic treatment.

The cross-sectional analysis of the life stories shows that a severe disorder of intersubjectivity starts in early adolescence, which should be a useful element to consider for the early detection and on the prevention. Beginning at an early stage, the patients progressively distance themselves from the social world, ending in a radical withdrawal. This distancing becomes a structural element, a key part of the prodromal stage of schizophrenia, as it was found in every case of the broader sample covering 15 patients with schizophrenia.

Social interactions are interrupted prior to the emergence of acute symptoms, possibly due to the threatening or anxiety provoking encounters with others. Nevertheless, the underlying anguish was not measured in this study. Instead, the study shows the personal vulnerability that leads to a psychotic break (or to the culmination of the intersubjective interruption).

Clinical Implications

Psychotherapeutic interventions for patients with schizophrenia have been widely neglected in general. Current treatments are primarily with medication, including elctroconvulsive treatments in acute phases, thus following a medical-biological model that has not been questioned sufficiently. In this context, the intersubjective dimension seems extremely relevant for both the development of psychological treatments and the understanding of the interpersonal processes involved in schizophrenia (as an interruption in intersubjectivity).

From the very start of hospitalization, psychotherapeutic support would appear of fundamental importance. The patients should be accompanied on their return to intersubjectivity, whereas efforts should be made to provide proper emotional support for the realization of the overall problem affecting them. Prior to interventions focused on tasks (for example, successfully performing a social role, such as studying or working), the patients need to experience being in the world with another person, in a synchronous accompaniment of affective reciprocity.

In other words, the intersubjective dimension should be integrated in psychotherapeutic models focusing on the patients’ social interactions. These models should be oriented to developing a collaborative encounter between the patient and the therapist, as well as enhancing metacognitive capacities, as it has been shown to be helpful especially for the recovery of patients with schizophrenia in several case studies (Dimaggio et al., 2008; Harder and Folke, 2012; Lysaker et al., 2013).

The process of recovering understandability would be a key aspect in overcoming the patients’ alienation. Therefore, special consideration should be given to psychotherapeutic approaches that focus upon encouraging patients’ self-understanding and the establishment of a common communicative base between patient and psychotherapist (Holma and Aaltonen, 1997, 2004a,b; Seikkula and Olson, 2003; Seikkula et al., 2006). The idea is that the patient’s experience can be explicitly shared on the basis of a common meaning by a dialog process that takes into account the other’s point of view (or second person-perspective; Stanghellini and Lysaker, 2007).

Patients’ narrativity should improve along different levels of articulation, by the recognition of beliefs, the incorporation of emotions and the reconstruction of different meaningful life events. However, during acute phases delusional beliefs constitute the patients’ only available form of cognitive and interpersonal organization, so instead of confronting them, the focus should be placed on the difficulty in pragmatically comprehending others and on the experience of vulnerability (Lysaker et al., 2011a,b,c; Salvatore et al., 2012a,b; Henriksen and Parnas, 2013; Škodlar et al., 2013).

Besides, acute psychosis in schizophrenia manifests itself with a collapse of the temporal dimension of the narrative plot, which leads to a de-contextualization of self-experience (Holma and Aaltonen, 1997, 2004a; France and Uhlin, 2006). From the so called “literacy hypothesis” (Havelock, 1980, 1991), which belongs to studies that follow the transition from orality to literacy in the development of the thematic consciousness, it could be noted that in the acute phase the patients lose the modality of ordering their experience in consensual logical sequences, displaying a narrativity with epic or poetic characteristics (Guidano, 1999).

The re-establishment of the consensual ordering given by the locational/situational aspects of the life story (by articulating the self-experience in thematic/chronological sequences; Havelock, 1980, 1991; Bruner and Weisser, 1991; Narasimhan, 1991; Guidano, 1999; Irarrázaval, 2003; Bruner, 2004; Holma and Aaltonen, 2004a) allows to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence.

In this sense, the articulation of the patients’ life stories, expressed as narrative creations of their own subjectivity (and meanings), allows for the spatiotemporal dimension “re-ordering,” as well as for the understanding of the interpersonal processes involved in schizophrenia from a broader perspective. This psychological understanding reveals the intersubjective dimension that connects the emergence of the acute episode with the patients’ biographies, taking into account the personal meaning at play in each case.

In the case of Santi, there appears to be a need for emotional support aimed at accompanying him in becoming aware of the magnitude of the loss caused by the recent death of his father and, subsequently, to help him to develop strategies to deal with his feeling of abandonment in the world.

With Angel, his fear of ridicule is a structural emotional trait that dominates his life and is becoming a fundamental part of his worldview. Here, it is most important to deal with his sense of embarrassment and help him to accept himself. The aim is to provide a new, positive meaning to the sense of himself, overcoming his fear of ridicule in his encounters with others, or in other words, recovering the legitimacy of the sense of himself.

Salva requires an intervention in terms of developing a more basic sense of self-embodiment, which would be aimed at reflecting the feelings of “the other,” to re-establish primordial reciprocity. Additionally, space needs to be created in which the patient can recover a feeling of protection in the world, overcoming the feeling of powerlessness.

From this viewpoint, taking into consideration the story the patient tells of himself improves the articulation of self-narrative, which should gradually be extended toward diverse areas of his life whose elaboration appears important for him to make his way back to daily life. It would be important to articulate the present considering the experience that takes place in the actual interpersonal context, and from here to articulate the future as a horizon of possibilities.

Therefore, reconstructing the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia, but also on the psychotherapeutic intervention best suited to each individual case. Moreover, when intervention in acute phases of schizophrenia focuses mainly on reducing “positive” symptomatology, without assessing the psychological and social elements that are part of the overall situation affecting the patient, relapse seems highly likely.

Limitations of the Study

Regarding the limitations of the study, mainstream scientific research in mental health has been dominated by quantitative methodologies and statistical analyses of big samples (representativeness), while the value of in-depth psychological analyses has been underestimated.

There is a predominant excessive confidence in the accuracy of numbers, as if they could not be easily manipulated in data analyses. This tendency has been supported by the illusion that numbers represent exactly (as a mathematical formula) the experience of the subject, rather than the patients’ own stories.

While qualitative methodology has been the tradition for research in humanities and social sciences, psychotherapy research has been developed using the methodologies of the medical sciences, which are mostly quantitative, being the randomized controlled trials being the favored design.

Nevertheless, research in psychotherapy should be guided by questions that are relevant to clinical practice. It should not be forgotten that methodologies are only means to carry out scientific research, but should not be the ultimate aim in themselves. Thus in this field of research it seems necessary to incorporate the questions psychotherapists need to answer to improve the practice of psychotherapy (to help patients), and then to choose the most appropriate methodologies.

However, one of the main advantages of qualitative studies is the open, mindful and detailed assessment of the subjective experience, enabling the emergence of the patients’ worldview and their personal meanings, which cannot be obtained by means of superficial assessments. Therefore, psychotherapists should also have a voice on the debate of which methodology is best suited to improving the practice of psychotherapy.

Future Directions

Certainly, it would be important to systematize the results of this study in a model of psychotherapeutic treatment for persons with schizophrenia, which should include the intersubjective dimension, starting from the hermeneutic analysis of the patients’ life-worlds toward a meaning-based psychotherapeutic practice. This model would eventually require evidence of effectiveness.

Moreover, it would be interesting to explore gender differences in the processes involved in schizophrenia, investigating prodromal and acute stages, as well as life stories of women with schizophrenia. In addition, improvement is needed regarding the differential diagnosis between acute phases of schizophrenia and acute phases of other severe mental disorders, such as major depression and bipolar disorder.

Finally, the future challenge in the field of phenomenological psychopathology would be to develop a comprehensive/unified philosophical framework for an embodied science of intersubjectivity. And, consistently, to continue developing coherent methodologies for empirical research, since this is the closest we can get to the patients’ life-worlds.

Author Contributions

Co-author Dariela Sharim made substantial contributions to the analysis and interpretation of data to include in the paper; she revised the paper critically for important intellectual content; she made a final approval of the actual version of the paper to be published; she agreed upon the accuracy and coherence of the development of the sections for the paper.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thank Thomas Fuchs from Heidelberg University, the Reviewers and the Editor for their helpful comments to improve the manuscript. Leonor Irarrázaval would like to thank Comisión Nacional de Investigación Científica y Tecnológica (CONICYT) for the grant “Beca Doctorado Nacional” (Doctorado en Psicoterapia UCH/PUC) and German Academic Exchange Service DAAD for the grant “Short duration research scholarships for doctoral students and young researchers.”

References available at the Frontiers site.