Wednesday, 27 May 2015

Schizophrenic Language as Disturbed Relating

There is a widespread intuition in psychopathology of a deep relationship between the opaque and confused conversation that manifests schizophrenic thought disorder and a disturbance in social relating. Different visions of human mindedness make for different theorisations of this relationship. Thus cognitive theories sometimes presume a separability of thought and communication; conversational disturbance is then chalked up to a failure in the use of social knowledge to constrain the apt presentation of intact thoughts. Phenomenological theories, by contrast, both eschew such a separation of thought and communication, and suggest a deeper relation between social relating and thought. In their ontological vision our capacity to think is not understood as antecedent to our capacity to communicate, and our individuation as distinct thinking subjects is not understood as antecedent to our capacity to relate. This understanding of the relation between selfhood, communication and thought helps us grasp in its formal aspect the depth of the relation between thought disorder and disturbed social relating, but requires supplementation from psychoanalytical psychology in order for us to truly grasp the nature of this relation in its living character: namely in terms of the essentially affective character of those meaningful social relationships in which selfhood and subjectivity are established. With an eye to both the phenomenological and the psychoanalytical traditions we can grasp how, through their effect on the constitution of subjectivity, relational difficulties affect the very constitution of such thought as is immanent in meaningful conversation.

1. Communication Disturbances and Disturbed Social Understanding - The Shape of the Argument

A prominent theme of recent work in psychopathology has been the centrality of disturbed social understanding in the phenomenology of psychosis. One well-known, cognitively oriented, researcher — Richard Bentall — argues that ‘abnormal social cognition is directly implicated in the behaviours and experiences that are the most obvious manifestations of madness’ (Bentall, 2003, p. 204). Another significant, phenomenological, writer — Giovanni Stanghellini — has described psychosis as emerging in part from a disturbance of ‘common sense’, which is to say, a disturbance of social knowledge and interpersonal attunement (Stanghellini, 2004, ch. 4). This trend revives an earlier theme as old as the concept of schizophrenia itself. Thus Eugen Bleuler, for example, described ‘autism’ (another of his coinages) – referring inter alia to social incompetence and withdrawal, indifference, rigid attitudes, disturbed hierarchies of values, and inappropriate behaviour – as, along with other essential disturbances in thought, feeling and integration, a fundamental symptom of those disorders he first termed ‘the schizophrenias’ (Bleuler, 1911/1950).
In what follows the focus will be on such disorders of thought as are characteristic of schizophrenic and related psychotic conditions. The intuitive theme to be unpacked is that thought disorders can in some way be understood as a function of a disturbance in our capacity for normal social understanding and relatedness. A cognitive psychological reading of this relationship as presented in Chris Frith’s (1994) theory of schizophrenia and Richard Bentall’s (2003) theory of psychosis will first be described. This theory reinterprets thought disorder as merely communication disorder — i.e. as a difficulty in getting one’s meanings, meanings which themselves are in good order, across to another — and views disturbed communication as resulting in part from a failure in the use of social knowledge to adequately constrain and inform merely the expression of thought.
This cognitive theory clearly requires that thought and linguistic communication can be separated out as distinct existences, such that bizarrely constituted conversation is no longer seen as simply criterial for disordered thought. This assumption is challenged below, and in its place a phenomenologically inspired ontological alternative is developed that stresses the immanence of thought in, rather than the anteriority of thought to, conversation. This reacquaints us with the original psychiatric intuition that disorders of thought are truly that, but simultaneously deprives us of the opportunity to grasp even that relation between disturbed social understanding and disturbed discourse as suggested by the cognitive theory. To grasp this relation anew we can however radicalise our grasp of the significance of human interaction and the shape of human thought by relying on a further existential-phenomenological understanding: that the constitution of the thinking subject is neither anterior nor posterior to, but rather of an ontological piece with, that subject’s participation in interpersonal life. By understanding quite how intimately subjectivity or selfhood and conversational intelligibility are related we can now begin to grasp, at a deeper level than the cognitivist, the formal character of the relation between disturbed talk and disturbed intersubjectivity. Still, however, the remaining account is precisely that – a merely formal account, with as yet none of the living, empathically ascertainable, intelligibility of a subject in formation in interaction with others. The remaining piece of the puzzle is provided by a psychoanalytic perspective, which provides us with the requisite focus on affect and subjectivity that otherwise eludes us, and enables us to grasp from the inside the lived and motivated character of those simultaneous disturbances of thought and relatedness.

2. The Phenomena of Disordered Thought

The psychiatric term ‘formal thought disorder’ is typically used to describe a range of disturbances in the form that thinking can take – as opposed to those disturbances of believing we know as ‘delusions’; in practice, of course, the two disturbances are often intermingled. Without pretending to yet articulate or empathically enter into the distinctive character of the difficulties in question, we may at least start by noting that the kind of thought we meet with here is that which has become somehow: circumstantial and tangential, dominated by irrelevant associations and longwinded deviations from the point; distractible, such that it may mid-flow be captured by irrelevant external stimuli; incoherent and illogical; clanging, when association becomes driven by sound rather than by inner meaningful connection; and idiosyncratic, in that eccentric neologisms may be coined, old words used in new ways, and pronouns and indexicals become inadequately explicated (Sims, 2002, ch. 8; Andreasen, 1979).
            As with many of the symptoms of schizophrenia, it is not easy to penetrate their being other than through sustained immersion in either clinical encounter or authentic life writing: lists in diagnostic manuals do little to give us a real feel for the phenomena in their distinctive peculiarity. The difficulty doubtless arises because we are apt – under the guidance of those implicit, sanity-constituting, intelligibility-rendering, procedural frames of reference in which we ourselves are necessarily and unreflectively embedded, and which we inexorably and unwittingly project into the background of whatever we encounter – to find our focus resting too readily on the easily articulable foreground- and content-related aspects of the psychological phenomena. Rather than, that is, on those essential yet hard-to-articulate disturbances in the background of the thought-disordered patient’s selfhood itself, disturbances which now can be merely sensed, which sensing yet thankfully often-enough constrains our grasp of the psychopathological phenomena.
Hence Emil Kraepelin (1919/2002, pp.56-7), admittedly not famed for his empathic sensibilities despite his seminal psychiatric contributions, tends to offer us mere fragments to explicate the concept: ‘A patient said “Life is a dessert-spoon,” another, “We are already standing in the spiral under a hammer,” a third, “Death will be awakened by the golden dagger” a forth, “The consecrated discourse cannot be split in any movement,” a patient, “I don’t know what I am to do here, it must be the aim, that means to steal with the gentlemen.” ’ Even so we perhaps begin to get a partial feel for the phenomenon. Other authors provide a little more; Chris Frith (1992, p. 99), for example, quotes Rochester & Martin (1979, p. 106): ‘Ever studied that sort of formation, block of ice in the ground? Well, it fights the permafrost, it pushes it away and lets things go up around it. You can see they’re like, they’re almost like a pattern with a flower. They start from the middle.’ Better still is that offered by Freeman, Cameron & McGhie (1966, p.101) ‘Interviewer: ‘How does the message get from one patient to another?’ Patient: ‘By slips – by slipism automation… some remote time – an umpteen multiplied by an upteen years ago … Very brainy and clever … They are very brainy criminals … nothing like these people … Slipism… … That’s been carried on like that and these people that puppet… The puppets have to show their slipism, the hair-blood and body-slip of you – the male nurses, the lunatics are their own persons, but they put it on by invisible strings – motivated automation by water, electricity, gas, and as many other such powers as can added and they have the affinity and the sympathy.’ Even here, however, the seasoned clinician must guard against too readily taking such examples to really show us, by themselves, the essential phenomenon – since he or she may here be reading them against the tacit backdrop of his or her own living familiarity with that phenomenon’s less readily articulable aspects.

3. A Cognitive Theory of the Relation between Disturbed Talk and Disturbed Relating

The cognitive theory I wish to consider here is presented in two stages. In the first, thought disorder is recast as communication disorder; in the second, communication disorder is related to a disturbance in the social understanding of the communicator.

3.1. A Cognitive Account of the Relation between Thought and Communication

Cognitive psychological accounts of thought disorder have sometimes cast doubt on the readiness of clinicians to infer disordered thought from a patient’s disordered speech. Bentall (2003, p. 381) recruits the work of Rochester & Martin (1979) to push the claim that, since the diagnosis of thought disorder is based on the incomprehensibility of the psychotic person’s speech, ‘the question ‘What is abnormal about psychotic thinking?’ should be replaced with the more useful question, ‘Why do ordinary listeners find psychotic speech so difficult to understand?’.’ Frith (1992, p. 97) also suggests that use of the term ‘thought disorder’ implies both that such disturbed speech is due to disturbed thoughts and that the “ability to put these thoughts into language is unimpaired”, and this is described as an “assumption [that] remains unproven.”
The thought is elaborated by Frith (1992, p. 97) as follows: ‘There is a fundamental difference between language and thought, which has received surprisingly little emphasis in the study of schizophrenia. Thinking is a private matter, whereas language is arguably the most important method we have for communicating with others. Thus language is not simply the expression of thoughts; it is the expression of thoughts in a manner designed to communicate these thoughts to others.’ The upshot is that we would do better to focus on what is supposedly all that we observe — that is, just on the disordered conversation of the ‘thought-disordered’ patient.

3.2. A Cognitive Account of the Relation between Communication and Social Understanding

Only with this separation between thought and discourse in place may we now proceed to the second stage of the cognitive theory. This has it that some of the failure in putting putatively intact thoughts into expressions adequate to the communicative situation is due to a failure of the speaker adequately to assess the semantic needs of the listener. In particular, the thought-disordered speaker may suffer from disturbances in their social comprehension which leaves them unable adequately to appraise their interlocutor’s prior understanding and knowledge of the topic of conversation. As Frith (1992, p. 100) concludes, ‘some schizophrenic ‘thought disorder’ reflects a disorder of communication, caused in part by a failure of the patient to take account of the listener’s knowledge in formulating their [own] speech.’ For example, the speaker fails adequately to assess what their listener already knows and what they do not yet know. The speaker thereby supplies their listener with irrelevant information, or they fail to provide the background information necessary for disambiguating, or fixing the reference of, what they are saying. Bentall (2003, p. 395) also cautiously supports this idea, citing the findings of Sarfati & Hardy-Bayle (1999) regarding an association between disturbed talk and disturbed social comprehension.
            It is important to note two things at this point. The first is that no cognitive theorist chalks up disturbed talk in schizophrenia only to disturbances in social comprehension; we are here only looking at how certain cognitive theories do theorise that relation, since this is the relation we are investigating here. The second is that it is only on the assumption that disturbances in talk and disturbances in thought can first be prised apart in the manner suggested by the cognitive psychologist that the theory (that disturbed talk is partly explicable in terms of the speaker’s failure to take account of the distinct knowledge, beliefs and intentions of the listener) can get off the ground. In what follows I make this clearer and provide a philosophical critique.

4. Philosophical Critique of the Cognitive Theory

Following Rochester & Martin (1979) both Bentall (2003) and Frith (1992) characterise the psychiatrist’s conception of the relation between thought disorder and incoherent talk in terms of ‘inference’ and ‘evidence’. Bentall (2003, pp. 381) urges, for example, that since ‘the only evidence of thought disorder is peculiar speech, speech and not thinking should be the focus of the psychopathologist’s inquiries’, and (ibid p. 382) lampoons the psychiatrist for circularity in allegedly encouraging us to ‘infer thought disorder from incoherent talk’ yet to explain disordered talk in schizophrenia in terms of underlying disordered talk, ‘so… thought disorder is when talk is incoherent… and talk is incoherent when the thought is disordered.’ Below I suggest that in truth we don’t meet here with evidence, inference and explanation but rather with criteria, entailment and characterisation – and that the appearance of circularity is therefore an artefact of the psychologist foisting their favourite (explicitly scientific and inferential) mode of reasoning onto the psychiatrist’s (implicitly phenomenological) mode of understanding. But first I wish to make clearer my claim above that the cognitive theory itself depends on our being able to prise apart the phenomena of disordered talk and disordered thought in a manner that might lead us to talk of their being linked by way of evidence or inference.
            The cognitive theory claims that disturbed talk is partly caused by a failure of the schizophrenic speaker to take account of the beliefs, knowledge, and intentions of their listener. This, it is suggested, is part of the reason why they don’t produce talk that is intelligible to their listener. And in order for the theorist to coherently suggest that my talk is confusing to you because what I will call here my ‘dissociality’ or interpersonal ineptitude prevents my taking account of what you need to know in order to grasp my meaning, it must be the case that I yet have a meaning that, were I not thus stricken by gaucheness of social comprehension, I would have conveyed. That, I am suggesting, is the force of this aspect of the cognitive theory. My ‘theory of mind’ disturbance is what gets in the way of my conveying my meaning in my talk; were it not for the putative ontological possibility that my meaning and my talk could come apart in this way, there would be no work for the cognitive theory to do. And this is because, were my incoherent talk instead simply a criterion of disordered thought, rather than a mere symptom of it or something which counts as mere evidence for it, then I would, as it were, require no help from my interpersonal ineptitude in order to be unable to make sense: I would not be making sense to you because I would not be making sense punkt.
What now of the idea that it is unfruitful to describe the disordered speech sometimes met with in cases of schizophrenia as due to a disorder of the form of thought? Here it is helpful to distinguish two forms of understanding. On the first, one thing is seen as intelligible to the extent that it can be causally related to that which produces it. On the second, one thing is seen as intelligible to the extent that it can be brought under a certain characterisation. With regards bodily movements and vocalisation, for example, we can explain their occurrence by relating them causally to prior, or causally recursive, neurological processes. With regards the relation of human discourse to the thought it expresses, however, we come to see it as meaningful, intelligible, rational, or thoughtful, to the extent that it can answer to certain descriptions and constraints. Is it cogent? Does it express a humanly intelligible desire? Does it hang together? Is it apt to the circumstances?
Occasionally some stretch of speech may be the result of prior planning or inner rehearsal, but a moment’s consideration reveals that most utterance is not thus consequent on cogitation. And any prior inner speech could itself be said to amount to the inner articulation of a thought only to the extent, again, that it meets certain standards of cogency. What this reveals however is not that the concept is psychopathologically unfruitful, but that it belongs to phenomenological characterisation rather than to causal explanation, drawing our attention as it does to speech in its meaningful rather than its motoric aspect. The concept of ‘thought disorder’ serves, that is, not to distinguish one rather than another cause of ideationally awry discourse, an inner cause that might be inferred from merely  external aspects of the discourse in order to explain their occurrence, but to distinguish discourse that is ideationally awry from that which is clumsy, lisping, phonetically inarticulate, grammatically ill-formed, etc.
To be sure, there are special occasions on which we may wish to predicate cogent thought of someone whose speech is yet confused. (Perhaps someone who has had a particular kind of stroke struggles, to their own great annoyance, to convey clear ideas in speech, but can yet write down what they want to say.) But here it is important to note that these precisely are special occasions, occasions in which, were it not for the provision of positive evidence that we do here merely have to do with an expressive difficulty, the ascription of thought disorder would be straightforward. It is straightforward, that is, since the cognitive disorder is immanent within, or characterises, the disordered discourse itself, rather than being something beyond it which, on its basis, is merely inferred to obtain.
To recap, the cognitive theory under consideration has it that disordered talk is a function of disordered interpersonal understanding to the extent that the latter mediates the expression of thought in an interpersonally viable manner. The above considerations, however, question whether anything like this could really be the case. And whilst we can all of us sometimes fail to express ourselves well because we fail to account of the listener’s needs – for example by using pronouns whilst forgetting to provide their referents – such difficulties are necessarily fairly trivial, and involve us recognising our mistake, apologising and correcting ourselves. One could even say that a condition of possibility for treating a particular disordered communication as a result of a failure to take account of the listener’s needs is that, in a deeper and more general sense, the speaker precisely is yet able to heed here the discursive requirements of her interlocutor, at least when called upon to do so. If she could not respond thus to the call of the other’s perplexity it is unclear what could motivate a continued ascription to her of failing to use social knowledge to help make her thought interpersonally available, rather than an ascription of confused thinking itself.
Considered as a piece of empirical psychology the cognitive psychologist’s version of the relation between dissociality and disordered discourse fails. In what follows I suggest that this does not mean that the intuition of such a relation must be abandoned, but rather that we need to consider it other than through the empirical psychologist’s lens of dissociality as a mediating variable.

5. Radicalising the Intuition Regarding the Relevance of Dissociality to Thought Disorder

We started with the intuition that it is helpful to understand thought-disordered discourse in relation to disturbed interpersonal relatedness. The cognitive psychologist’s construal of the relation in terms of a mediating effect fails. It does so because it simultaneously fails, in relation to grasping sane mindedness, to respect the immanence of thought in discourse and, in relation to grasping schizophrenic psychopathology, and by taking the issue to be merely one of the expressive mediation of thought, to do justice to the depths of the psychotic disturbance to thought in itself. The suggestion to be pursued here is that we may, however, save our original intuition by radicalising it – by casting in an ontological light what the cognitive psychologist proffers merely as a piece of empirical psychological theorising.
Above it was suggested that thought is constitutively related to the discourse which expresses it, characterising its form rather than causing it to be. The suggestion now on the table is that sociality – our capacity to respect one another’s semantic needs in conversation – is similarly to be understood as constitutive of meaningful discourse, rather than as an external, merely mediating, factor in its production.
This can be harder to grasp than the consideration that thought is constitutive of rather than antecedent to discourse, but just as that latter consideration is best appreciated through considering cases of thought immanent within spontaneous intelligent speech, so too we can best grasp the significance of sociality to thought by thinking first and foremost of spontaneous meaningful social interaction.
So here I am, unreflectively chatting with my neighbour, telling him something of a few of the events of the day, updating him about the antics of the baby swallows nesting under our eaves, pondering what we’re going to do with the troublesome issue of haphazard refuse collection, letting the conversation go where it will, responding spontaneously to what he says. The suggestion on the table here is that such quotidian social situations are the existential home of thought itself. Not only is it apt to see thought as internal to discourse, but discourse is itself to be considered internal to conversation.
Consider again the idea that to be a conversationalist it is necessary that I be able to take account of the beliefs and intentions of my interlocutors. A natural way of spelling out what this means is in terms of my tailoring the expression of my pre-individuated thoughts to what I appreciate of the needs of the other. On this reading taking account amounts to an intellectual achievement. But on another reading we can instead focus on the conversation as the original founding context for individuating such thoughts in the first place – on this reading it is the originary context of intersubjectivity which provides the cloth for the very thoughts themselves. We may abstract away from such conversations once we have learned to participate in them; we may go on to have them with ourselves, or with imaginary interlocutors. We may become so fluent at this that we can even sit writing thoughtful articles without first discussing their content with others. Yet, so the thought goes, our facility in carrying on the human conversation in the privacy of our own crania should not mislead us into narcissistically taking such crania to be the ontological cradles of thought (Hobson, 2002). The cradle of thought is, rather, the human conversation; it is the human conversation which wears the trousers, and I who must learn to wear them before I can arrogate to myself the privileged designator ‘thinker’ and, perhaps, go on to cogitate in private.
In this conversation with my neighbour, then, it is essential that I am embedded already in a shared context with him, that of being neighbours here, both living beneath these nesting swallows, both using the same refuse bins, and both speaking the same language. Yet this consensual and informing matrix also contains my implicit understanding of what is not known to my neighbour: it is this, after all, which gives conversation its point. (It is this, too, which may be lost in the mute patient who delusionally believes that others know their thoughts and thus there is no point in communicating them.) The important claim on the table here, though, is that it is my dwelling in such an implicit and informing matrix which frames the very generation of such thoughts as are immanent in my conversation, and this is not simply a matter of tailoring my words to get my point across. My taking account of what the other does and doesn’t know obtains against a background of my thought itself already taking for granted something about what they do and don’t comprehend.
A corollary of this is that foundational sociality has little to do with putting ourselves in the shoes of another, of correctly intuiting what others think when that is different from what we think etc. Sociality is in this sense precisely not an intellectual achievement, but rather a matter of being able to be in relation to others; it references the fact that, to the extent that we are thinking subjects, we are always already in one another’s shoes (Heidegger, 1962, section I.5.34). Contrast those cases of disordered communication – imagine you asking me, perplexed, ‘but Richard what do you mean by ‘x’?’ – which i) have to do with my not conveying my thoughts clearly but going on to put this right, with those which ii) have me come to see how I had not been having a coherent thought in the first place, where the cog of my thinking has become detached from that mechanism which is the social medium of true thought. The thesis that the intuition regarding the relation between disordered discourse and dissociality is best unpacked ontologically rather than as a piece of empirical psychology – as having to do with the inner coherence of the being of the thinking subject, rather than externally in terms of a merely disturbed communication – assimilates thought disorder to ii) and not to i). The thought-disordered subject is not making sense in his thinking itself because he has unwittingly fallen off the conversational rails.
To return to a case of thought disorder cited by Frith (1992, p. 99) and quoted above (Rochester & Martin, 1979):

Ever studied that sort of formation, block of ice in the ground? Well, it fights the permafrost, it pushes it away and lets things go up around it. You can see they’re like, they’re almost like a pattern with a flower. They start from the middle.

Of this Frith (1992, p. 99) says:

The speaker provides no antecedent for “they”. Apparently, he assumes that the listener already knows who or what they are. Possibly he had snowflakes in mind.

By contrast, what is being suggested here is that a failure in the patient’s sense of what the listener already knows is not a cause of their failing to adequately articulate something (a thought about snowflakes) that they have in mind, but is rather constitutive of their failing to have a coherent thought in the first place. Furthermore, this failure of interpersonal understanding can be seen to amount not to a faulty assumption on the part of the thought-disordered patient, but to a lack of that pre-reflective social attunement necessary for entering into the space of conversation and thereby into the ontological cradle of thought itself.

6. Thought Disorder as an Emotional Disturbance of Relating

The above ontological analysis recaptures the psychotic depth of thought disorder and ably theorises its relation to dissociality. Nevertheless the account remains purely formal and, besides reminding us of the bare fact of disturbed relatedness of the thought-disordered subject, fails to provide an empathic entry point into his or her world. To effect this it is necessary to bridge matters of ontological form with matters of empathically graspable content; the remainder of this article reminds us of how psychoanalytical psychology achieves this.
The patient who becomes thought disordered is rarely thought disordered in general; rather they become both thought disordered and delusional in the ambit of their complexes, i.e. when touching on material that through its emotional salience overwhelms their capacity to think (Jung 1906/1936). In his word association experiments Jung found the following disruptive effects on the form of verbal associations to complex-triggering terms in patients with dementia praecox who nevertheless showed no other direct signs of emotion: pronounced inhibitions of the thinking process; manneristic and perseverative repetitions of particular terms; wishful and fearful grandiose, persecutory and erotic fantasies; confusions of identity; suppressed complaints; neologisms; and primary process (dream-like) forms of thought (e.g. condensation of different ideas into one and wish-fulfilments). Despite being able to converse clearly and in a reality-oriented manner about many topics, when the conversation touches on matters that come close to unbearable wounds to the emotional fabric of the self – to great gashes in their self-esteem regarding their occupational and familial and romantic prowess, to areas of dementingly intolerable shame, to topics arousing inescapably conflictual desires (e.g. loving and hating the same object) – in short, to matters that Freud (1924/1979) described as rents in the fabric of the ego – the patient’s thought becomes disordered. And these wounds are always disturbances of self-in-relation-to-others; they always speak to a disturbance of relating.
Leaving aside the developments of post-Kleinians such as Bion (1984) and Rosenfeld (1950) who view thought disorder as motivated mental self-mutilation, the psychoanalytical psychology of thought disorder shows remarkable consilience across different theoretical orientations (Freud (1924/1979), Jung (1936), Leader (2011), Sechehaye (1956), Freeman et al (1966)). To extract its essential features: The schizophrenic subject shows a lack of resilience in their self-identity in particular aspects of emotionally charged relationships with particular others who are experienced as controlling, intrusive, rejecting, etc. – either because others are such things, or because such relationships are already dramatically coloured by the patient’s projections. Their fragility concerns their relations to others in matters of prestige, recognition, love, unreciprocated sexual desire, dominance, valuation and definition; a fragility which may arise from constitution, a general milieu of unsupportive relationships in early life, or discrete shaming and shocking traumata. Such sore points or complexes are too overwhelming to be thought about; reality contact (i.e. the ability to distinguish reality from imagination, things from thoughts) is lost; and a state of mind is arrived at which both shows considerable similarity to the dream state of non-psychotic subjects, and which is radically insulated from emotional contact with others (‘autism’). It is this state of radical emotional detachment and preoccupation by an idiosyncratic, a-social, inner domain of purely personal meaning that is so palpable to their interlocutor, and which gives rise to their interlocutor’s distinctive ‘praecox feeling’.
According to the general psychoanalytical model the essential features of thought disorder are either to be understood as direct manifestations of, and/or as compensatory responses to, the activation of the complexes. Thus delayed reaction times, pronounced pauses, and gross disorganisation represent the overwhelm of the thinking apparatus. Other symptoms, in particular tangential (‘knight’s move’) thought and thought that conflates things with the words which represent them (‘symbolic equations’ in Klein; a breakdown of the ‘symbolic order’ in Lacan), represent a combination of disorganised overwhelm and a motivated move away from areas that provoke emotional distress – i.e. ‘displacement’. Ideas that are too raw to be thought about directly thereby meet with more emotionally acceptable substitutions of the sort Freud claimed to find at work in dreams. Yet other symptoms – in particular neologisms – represent direct compensations against psychotic overwhelm: idiosyncratic, manneristic and perseverative terms serve to ‘seal associative pathways’ (Leader, p. 107), providing reassuringly fixed nodes of personal and self-ratifying preoccupation that help the subject avoid interpersonally vulnerable areas of emotional overwhelm and maintain at least some degree of inner stability. It is in this compensatory function that thought disorder and such delusion as provide a patch over the rent in the ego overlap – or, to put it otherwise, and to the extent that delusion is characterised as such by its function: that what we might recognise as the delusionality of thought disorder obtains.
One way to avoid taking the psychoanalytical theory seriously would be to insist that its viability rests on the extent to which complex activation and thought disorder can be independently measured and then correlated positively. The difficulty with this would be that the very same conversational behaviour would surely often enough be criterial both for the emotional vulnerability and for the disordered thought, resulting in explanatory circularity. It might perhaps be possible to tease apart purely grammatical and syntactic aspects of disordered communication and correlate these with such aspects as speak to emotional disturbance. However what pursuing this analytical procedure sacrifices on the alter of operationalization is just what the ontological and psychoanalytical theories provide by way of phenomenological perspicuity: that what makes for distinctly schizophrenic thought disorder is conversation which, in its stumbling and frantic derailings and evasions of meaning, itself expresses the emotional pain of fragmented selfhood.

7. Conclusion

By taking the ontological approach to disordered communication suggested by the phenomenological psychiatrist we grasp the phenomenon in its formal character. The phenomena of disturbed talk, disturbed thought and disturbed selfhood are seen as of an ontological piece with a disturbance to such human conversation as is the ontological home of thought itself. By contrast with what the empirical psychologist opines, nothing in the ontological analysis suggests that it is methodologically unsafe to move away from observation of discursive behaviour to consider the form of human thought and selfhood themselves. This is because, on the one hand, conversation understood ontologically is itself the birthplace of human subjectivity and thought and so there would be no ‘moving away’ to be done, and on the other, we would only be imagining that we had to do with potentially unsafe inferences from the behavioural to the mental if we had, in what is itself an unsafe moment of our theorising, illegitimately divided up the phenomenon into inner and outer aspects which are then imagined to enjoy a merely external relationship to one another.
Although we can now understand the phenomenon as a disturbance of human relating – as a disturbance to that relating in which selfhood and thought is born – we are as yet without a means to grasp it empathically. Intuitively, however, the disturbance to subjectivity which the thought disordered subject manifests is one which we can feel in our interaction with them. The interaction jars and disorients us in a way which a merely syntactic disturbance does not. However psychoanalytic psychology now provides us with a way to start to do empathic justice to the inner situation of the thought disordered subject. The inconsequentiality, the derailment, the deep idiosyncrasies and bizarreness, the stiltedness, the displacements and condensations of meaning, the privacy of meaning, and the perseverations of schizophrenic discourse are now intelligible as a function of their speaker being, in his or her relating, on the run from such emotional experience as both constitutes, and threatens to overwhelm, selfhood.
A question that remains is whether such intelligibility enters into the essential being of schizophrenic thought disorder as such, or whether it remains an empirical observation about many instances of it. Or, in terms of Bleuler’s (1911/1950) famous four As, whether disturbances in association in an autistic mode of a sort that constitutes formal thought disorder are always-already implicitly understood by us as a disturbance in affect and ambivalence. What follows is not an attempt to answer this question definitively, but an articulation of the case for offering ontological status to the psychoanalytical theory.
Consider: Marjorie interacts well, intelligibly, helpfully with the ‘understanding psychosis’ inpatient group, but when it comes to talk of psychosis she tells us ‘Yes I understand what psychosis is: the ‘p’ is for peace, ‘s’ for sweetness, ‘y’ for young at heart, ‘c’ for charity…’ etc. Later she talks of going back home to see her husband whom she delusionally suspects of infidelity. I ask if she has faith in him yet and she tells me ‘yes I trust him with my mind and my body and my legs and my sternum and my cat and my car’. What my report of her words fails to convey is her lack of self-conscious confusion, her insistence, the tang of mute fury that accompanies her talk at such times, yet her incongruously cheerful overt affect, and her strong resistance to attempts to clarify or correct what she says.
What Marjorie’s words precisely do not explicitly speak of is what is nevertheless her very real terror at her own mind falling apart in psychosis, her fury at her husband and her fear of her own emotional dependence on him. What we are considering here, however, is the possibility that her apparent insouciance yet latent antipathy, the blitheness of her dismantling of the institutions of human relating and meaning, partly constitutes the being of her thought disorder itself. Our recognition of this may be latent or obscure, we may at first focally attend to the semantic and syntactic disruptions her discourse evinces. Yet, I am suggesting, perhaps what makes for paradigmatic – i.e. specifically schizophrenic – thought disorder is in part her manner of relating at such times – aloof, superior, hostile – a manner which does not simply constitute a form of participation within the human conversation but which in its assault on the foundations of such interpersonal relatedness shakes the very foundations of the ontological home of thought itself.


Andreasen, N. (1979). Thought, language and communication disorders 2: Diagnostic significance. Archives of General Psychiatry, 36, 1325—1330.
Bentall, R. (2003). Madness explained: Psychosis and human nature. London: Penguin Books Ltd.
Bion. W. (1984). Attacks on linking. Ch. 8. in W. Bion, Second Thoughts. London: Karnac.
Bleuler, E. (1911/1950). Dementia praecox or the group of schizophrenias. New York: International Universities Press.
Freeman, T., J. Cameron & A. McGhie (1966). Studies on psychosis. New York: International Universities Press.
Freud, S. (1924/1979). Neurosis and psychosis. In The Pelican Freud Library Volume 10: On Psychopathology. Harmondsworth: Penguin.
Frith, C. (1992). The cognitive neuropsychology of schizophrenia. Hove: Erlbaum.
Heidegger, M. (1962). Being and time. Oxford: Blackwell.
Hobson, P. (2002). The cradle of thought. London: Macmillan.
Jung, C. (1936). The psychology of dementia praecox. USA: Nervous and Mental Disease Publishing Company.
Kraepelin (1919/2002). Dementia praecox and paraphrenia. Bristol: Thoemmes Press.
Leader, D. (2011). What is madness? London: Penguin.
Rochester, S. & Martin, J. R. (1979). Crazy talk: A study of the discourse of psychotic speakers. New York: Plenum.
Rosenfeld (1950). Notes on the psychopathology of confusional states in chronic schizophrenias. International Journal of Psychoanalysis 28: 304-20.
Sarfati, Y. & M. C. Hardy-Bayle (1999). How do people with schizophrenia explain the behaviour of others? A study of theory of mind and its relationship to thought and speech disorganization in schizophrenia. Psychological Medicine, 29: 613-20.
Sechehaye, M. (1956). A new psychotherapy in schizophrenia. New York: Grune & Stratton.
Sims, A. (2002). Symptoms in the mind: An introduction to descriptive psychopathology. London: Elsevier.  

Stanghellini, G. (2004). Disembodied spirits and deanimated bodies: The psychopathology of common sense. Oxford: Oxford University Press.