Tuesday, 26 July 2016

disturbance of ego boundary enaction in schizophrenia

Draft of a paper submitted to PPP journal...

Abstract

The psychopathology of schizophrenic conditions is today often characterised merely in diverse and disjunctive symptomatic terms. Classically, however, what was understood to underpin and unify such diverse symptoms was a deficit in ‘self’ or ‘ego’, especially in that ego’s boundaries. As psychoanalytic and phenomenological theories have become less influential in psychiatry, concepts like ‘self’ or ‘ego’, ‘self-other distinction’ or ‘ego boundary’, have become less popular as psychopathological organisers, with the result that the very idea of a distinctively ‘schizophrenic’ condition has itself appeared to want for validity. Yet within the philosophy of psychology, enactivism provides a new naturalistic framework for understanding the emergence and maintenance of the self-other distinction. This framework considers the distinction neither as something constituted a priori to experience, nor as something showing up within experience, but rather as a continuously enacted achievement. The contention of this paper is that an enactivist perspective provides us with the apparatus to re-theorise the conception of ego-boundaries, contribute to the re-unification of the ‘schizophrenia’ concept, and inform the provision of therapies targeted at the schizophrenic diathesis itself.

I. introduction

Today the concept of ‘schizophrenia’ is often presented in psychiatric texts as a construct, a construct bringing together a diverse and, allegedly, independently assayable range of signs and symptoms (e.g. Rose 1994; APA 2013). According to such criteria two patients may both be allowed to count as suffering from schizophrenia despite sharing hardly a single symptom. The validity of the concept has accordingly been contested by psychologists for its apparent lack of unity (e.g. Bentall 2003; Boyle 2002). In the absence of clear independent evidence of a unitary physiological disease process underlying such diverse phenomena, a natural enough suggestion has been to abandon the diagnosis altogether and instead focus on and treat the putatively individual difficulties encountered by the patient (e.g. BPS 2000; BPS 2014).

What however is striking about many of both today’s psychiatric proponents and their psychological critics of this operationalised diagnosis is what could be called their ‘positivism’. By ‘positivism’ I mean here an allegiance to the idea that psychiatric illness concepts such as ‘schizophrenia’, and conditions of psychological disturbance more generally, are best conceptualised precisely as constructs, constructs of independently assayable symptoms, hence readily operationalised, their only meaningful conceptual unifiers being either an (elusive) underlying neurological cause or a (seemingly non-existent) homogeneous symptomatic presentation. One possibility that must therefore be considered is that the schizophrenia diagnosis falls apart not out of any intrinsic lack of unity to the condition, but rather because the positivist’s construal of it as mere construct itself already implicitly decides against any formulation of it as embodying a unified gestalt to be comprehended in terms other than those of cognitive, behavioural or experiential signs and symptoms or those of causal mechanisms underlying these symptoms.

By contrast with this positivist perspective, classic earlier conceptualisations frequently hinted, albeit vaguely, at a distinctive pathogonomic core to the condition – characterized not in terms of a single biological disease process but rather in terms of phenomenological character. Thus Kraepelin (1896) talked of a ‘peculiar destruction’ or ‘loss of inner unity’ of consciousness. Bleuler (1911, p. 143) noted that the patient's ‘ego’ tends to undergo ‘the most manifold alterations’; with this ‘basic disorder of personality’ ‘the ‘I’ is… never completely intact’. Minkowski (1927) asserted that ‘madness ... does not originate in the disorders of judgement, perception or will’, but rather in ‘the derangement of the innermost structure of the self’. And Schneider (1959) described how many of his ‘first rank symptoms’ involved a disturbance of ‘ego boundaries’. The strong impression one gets from reading such literature is that the concept of ‘schizophrenia’ was not originally intended to be understood in terms of its symptoms, unified at best either through empirical correlation or through the correlated symptoms flowing from a particular underlying neurological disturbance, but rather in terms of an (admittedly elusive) singular disturbance of the ‘ego’. Furthermore, this conception of schizophrenia as fundamentally a self-disturbance has, in the 21st century renaissance of phenomenological psychiatry, now been consolidated in the work of Sass & Parnas (2003), Lysaker & Lysaker (2008), Stanghellini (2004), Fuchs (2013), Mishara (2007), Maggini & Raballo (2004), and many others.

The stable identity of the self consists in such inter-related aspects as its clear delineation from its environment and other selves (i.e. the ‘ego boundary’ aspect), its inner coherence (disturbances in which Bleuler called ‘ambivalence’) and its diachronic continuity (self-sameness over time). These deep structures of personal being are not normally the object of our focal awareness of (either ourselves or) others. Instead we tacitly take for granted their obtaining in others when we attribute to one another those straightforwardly intelligible beliefs, experiences, understandings, knowledge, desires, and emotions which presuppose the basic structural integrity of the subject. Clinically our most reliable indicator of disturbed selfhood may therefore often only be that distinctive praecox gefühl - an intuitive felt sense that here we meet someone with a radically disintegrated ego, of a sort we are inclined to label ‘schizophrenic’ – a felt sense with a surprising diagnostic reliability (Varga 2013). Without meaning to downplay the significance of disturbances of continuity and coherence, what follows restricts attention to the structural feature of selfhood known as the ego boundary, disturbances of which have been considered particularly pathognomic of schizophrenia (Freeman, Cameron & McGhie 1958).

The question now arising is of course what exactly is meant by an ‘ego’, ‘self’ or ‘I’ disturbance (I use these terms indistinguishably) and how to think of its boundaries. Two possibilities will be canvassed below before being rejected. These I call the ‘metaphysical’ and the ‘epistemological’ approaches. The former approach, which colours some psychoanalytical accounts, reifies the ego boundary into a kind of metaphysical membrane; this gestures towards the ontological depths of the disturbance but renders it mysterious and recalcitrant to naturalistic analysis. The latter approach, which colours certain phenomenological presentations, attempts to grasp the concept in terms of a disturbed character to one’s experience of oneself. Whilst such disturbances are of course prevalent in schizophrenia I reject the idea that such a notion captures the ontological depths of derangement of the ego: a focus solely on disturbed self experience risks downplaying the significance of disturbances to selfhood itself.

My positive suggestion will be that an enactivist approach enables us to overcome the limitations of metaphysical and epistemological approaches, whilst yet theorising the ontological depths of schizophrenic self-disturbance. In this way we may exceed a positivist account by offering a unified account of distinctly schizophrenic disturbance while at the same time offering the theory in a naturalistic register satisfying to today’s scientifically minded psychiatrist and psychologist.

II. disturbed ego boundaries in schizophrenia: two perspectives

a. Metaphysical perspective

The term ‘ego boundaries’ seems to have originated with Victor Tausk and appears in his classic (1919/1933, p. 534) paper on the influencing machine in schizophrenia. As regards schizophrenia it is however most associated with Paul Federn (1953), although Sigmund Freud also clearly described the notion:

‘Pathology has made us acquainted with a great number of states in which the boundary lines between the ego and external world become uncertain or in which they are actually drawn incorrectly. There are cases in which parts of a person’s own body, even portions of his own mental life - his perceptions, thoughts and feelings -, appear alien to him and as not belonging to his ego; there are other cases in which he ascribes to the external world things that clearly originate in his own ego and that ought to be acknowledged by it.’ (Freud 1930/1985, p. 253).

Ego boundary loss was described by Federn as resulting from a lack of ‘cathexis of the ego’ by libidinal, aggressive and life energies. This resulted in a weakening of the ego boundary, itself understood by him as the outer limit of a subject’s ego feeling, a feeling that ‘sharply distinguishes everything that belongs to the ego in an actual moment of life from all the other mental elements and complexes not actually included in the ego’ (Federn 1953). Consider also the following:

‘The ego boundary takes on the function of a sensory organ in order to become aware of everything that goes on outside the ego. What is sensed as thought is a process occurring within the mental and physical ego boundary, what is sensed as real lies outside the body. … The … deterioration of the ego boundary results in a failure to differentiate the self from the outside world…’ (Freeman, Cameron & McGhie 1958, p. 33).

I quote these examples here both because they provide us with early suggestive and significant attempts at a unifying explanation of schizophrenic phenomenology, yet also because they exemplify some of the under-theorised, obscure and what above I called ‘metaphysical’ tendencies in early psychoanalytical theory. Thus here we meet the physiological metaphor of energetic cathexes taken from 19th century neurology and imported into psychology by Freud, an ego with a boundary that at times becomes a literal wall, or an ego as sense organ. How we are to naturalistically investigate these rather mythical-sounding entities, energies, membranes and non-standard sense organs is unclear. As is whether such a concept of a deteriorating ego boundary or a failure in its libidinal cathexis is clear enough to explain, rather than merely re-describe, a failure in differentiation of self from world.

b. Epistemological perspective

The concept of ‘ego boundary’ is used, too, in a significant way by prominent non-psychoanalytic writers as a unifier of a good portion of the schizophrenic symptomatology. Thus Fish tells of how the ‘boundaries between the ego and the external world disappear’ (1976, p. 32). Schneider suggests that many first rank symptoms can be ‘regarded as a group which represent the “lowering” of the “barrier” between the self and the surrounding world, the loss of the very contours of the self.’ (1959, p. 134). However it is Scharfetter (1995) – who I here take as representative of phenomenological perspectives in psychiatry – who has done the most to articulate the comprehensive spread of ego disturbances in schizophrenia, including what he calls disturbances of ‘ego demarcation’ (i.e. boundary disturbances) in his factor-analysed psychopathological scheme which also covers disturbances of ego vitality, identity, consistency and activity.

As against the ‘metaphysical’ habit of talking of the ego and its boundaries as if they were entities (‘We cannot “objectify” this empirical ego to a concrete “thing”’ (p. 48)) Scharfetter (1995) proposes, in Kantian spirit, a demythologising ‘regulative’ use of the concept of ‘ego’ - as a heuristic to structure or guide our observation and theorising about schizophrenic psychopathology (pp. 48-9):

‘Clinical experience with schizophrenics and a careful attention to their direct or indirect self-disclosure leads again and again to the ego-disorder as the core of their suffering. They are uncertain about or have lost the most elementary aspects of their self-experience, of their ego-consciousness, which is for mentally healthy people so naturally given, that they do not even reflect on these basic ego-aspects: to realise oneself as living, as active in receiving information, in reactions and intentional activities, as a consistent and coherent psycho-physical whole, as delimited from and thereby communicating with non-ego “objects”, as having an identity in the most basic sense of the world (to know who one is concerning mind, body, shape, physiognomy, gender, biographically and family-defined individuality etc.).’

In spelling out what disturbances of ego demarcation involve he writes (p. 70) of an:

‘Uncertainty concerning, weakness or lack of the differentiation between, ego and non-ego spheres. Deficit of a private sheltered realm of body-experience, thinking, feeling. Disturbance of the discrimination of inner and outer, of personal and external fields. … Ego demarcation allows us not only to be sure of our own private realm of experiencing of mental events but at the same time to communicate by the passage through the transparent boundary outwards (centrifugally) and inwards (centripetally). Ego-demarcation may be seen as a basic prerequisite as well as a result of a defined, i.e. delimited ego-identity.’

Such talk of communicating by passage through a transparent boundary is perhaps not all that clear. However clarity is provided by way of a range of first-person reports (p. 62):

‘I do not know my boundaries; I am unable to differentiate between inside and outside myself; I feel unsheltered; Parts of the body are outside myself; My brain is outside myself; I feel unprotected; Everything is intruding into me, penetrates me; What others think is transferred into me; What I suffer all others have to bear; I cannot keep my thoughts to myself, everybody can know them; I feel unsheltered and open for every external influence.’

Scharfetter’s study thereby avoids metaphysical obscurity by focusing predominantly on the self-experience of schizophrenic subjects. In his empirical investigations he explicitly restricts himself, that is, to what he calls the ‘experiential’ or ‘empirical’ ego - to the self as in some sense given to, experienced, or reflected on, by itself. In the terms provided by his Kantian framework Scharfetter leaves to one side the ‘transcendental ego’ - i.e. that ego the unity, coherence and boundedness of which is presupposed by any sane experiential, reflective or self-reflective encounter or act - perhaps because, within this Kantian framework, it is not considered amenable to empirical investigation.  Thus whilst at times he considers the ego as the core of waking consciousness (p. 4), as a ‘center of control for afferent and efferent procedures’ etc., the predominant focus in this (1995) work is on the ego as ‘core of self-awareness’ (p. 3). However the result of this is something of a shift away from central ontological issues about (say) the boundedness of the self to epistemological concerns about whether the location of the boundary is correctly appreciated by the self-conscious subject.

The above-quoted passage from Freud itself shows up a tendency in the literature for ontological questions to be run together with epistemic ones in a way which impedes our grasp of the fundamental ontological damage in schizophrenic selfhood. Thus Freud talks [my italics] of the ‘boundary lines between the ego and external world [becoming] uncertain or in which they are actually drawn incorrectly’. Yet if we are to allow ourselves talk of an ego boundary here being ‘drawn incorrectly’ by a subject, then there must here already exist some actual boundary between subject and world which has not been correctly represented or (in Scharfetter’s terms) discriminated. Tausk (1919/33, p. 534 [my italics]) put it similarly: “The patient seems no longer to realize that he is a separate psychical entity, an ego with individual boundaries.” The more radical proposal I wish to investigate here, however, is that in schizophrenia we do truly meet with ontological disturbances of the ego - disturbances in the constitution of selfhood itself - and that such a disturbance is central to the very meaning of schizophrenia. In line with Laing (1960), I propose that rather than misapprehending the placement of their boundary, the person with true ego boundary damage simply lacks any clear boundary to apprehend.

Schneider tells us (1959, p. 134) that whilst a good range of his first rank symptoms (especially passivity experiences) may be accounted for through the notion of ego boundary disturbance, others (hearing voices and delusional perceptions) may not ‘without resorting to speculative constructions’. In what follows I consider whether careful theorising along enactivist lines may take us further than speculative construction.

III. enactive constitution of the self-other distinction

To recap: three perils befall our understanding of this most fundamental marker of schizophrenic illness. Either (i) the concept of ‘schizophrenia’ is treated ‘positivistically’ as a mere construct of diverse readily identified cognitive, behavioural and experiential signs and symptoms, and the intuitively understood yet theoretically opaque ego disturbances such as loss of boundaries - this assault on the core of the living personality of the schizophrenic subject - is overlooked. Whilst this may do something for diagnostic reliability the risk is of endangering diagnostic validity and clinical sensibility by emptying the concept of its psychopathological unity and significance. Or (ii) core schizophrenic disturbances are acknowledged but receive a merely ‘epistemological’ treatment, boundary issues theorised as merely to do with errors in a subject’s grasp of where they end and the world or other begins; the ego disturbance is thereby underestimated in both depth and pathogenetic potency. Or iii) disturbances of the ego and its boundaries are not only acknowledged but reified into disturbances in some kind of ‘metaphysical’ organism or sense-organ; this however renders them recalcitrant to naturalistic analysis.

I now present an enactivist perspective on ego boundaries (in this section) and their disturbance (in the next). By enactivism I understand that philosophy of mind which rejects a view of perception as input to, and action as output from, a pre-delineated inner domain of inner representations, and proposes instead that an environmentally situated organism’s fundamental mental structures and contents are themselves created and reinforced by cycles of sensori-motor activity such as interacting with perceived objects and taking part in conversations (Varela, Thompson & Rosch 1992; Thompson 2007; Hurley 1998). In this section I suggest - through elaborating a series of 5 enactivist tenets - that a key strength of an enactivist theory of the self is what it affords by way of relief from what I described above as the under-theorised ‘epistemological’, and hyperbolically ‘metaphysical’, tendencies as they affect our grasp of the relationship between selfhood and our sensorimotor lives. The particular aspect of selfhood I focus on is, in keeping with our focus on ‘ego boundaries’, the distinction between self and not-self - although I do not mean to imply by this focus that this aspect of selfhood is not itself internally related to other key aspects of selfhood such as the self’s inner integration and diachronic coherence. The following section will then apply this enactivist framework back to the case of schizophrenic illness.

a. The ego boundary is enacted equiprimordially with experience. The particular claim on offer here is that the boundary between self and world is not best understood as something independent of and prior to our experiential encounters with the world about us. Rather, the distinction between self and world arises equiprimordially with that self’s perception of their environment. In terms of enactivism’s favourite poetic metaphor – ‘Wanderer the road is your footsteps, nothing else; you lay down a path in walking’ (Machado, 1979) - the path of the ego boundary is laid down at the same time as the walking of perceptual experience. As against ‘metaphysical’ perspectives, the ego boundary is not some non-natural entity that already bounds a self before that self enjoys any experiential encounters. And as against ‘epistemological’ perspectives, the ego boundary is not constituted within experience - it does not first and foremost show up, for example, as something itself experienced. Instead it co-arises with the self’s perception of its world and is its co-constituting condition of possibility.

b. The ego that is boundaried is first and foremost a corporeal subject. As against a view that the self is merely contingently embodied, enactivists understand it as essentially corporeal, especially in its most fundamental aspects - i.e. in those aspects that ground and shape the rest of the psyche’s structure and function. Drawing on existential phenomenology, enactivists view this corporeality not in terms of a subject’s material identity with a mere (extensional, fleshy, skin-delimited) physical object, but rather with a (living, intentionality-imbued) sensori-motor body-subject (Thompson, 2007). This sensori-motor subject is largely but not always co-extensive with the physical body; the sensori-motor apparatus that constitutes the itself-un-encountered from-where of our experience may include the blind man’s cane, the pen in our hand as we feel - not in our fingers but at the pen’s point - the bumps on the page underneath it, the spectacles or binoculars pressed to our face, and so on. Or it may include less than the physical body, as in those neurological and psychiatric cases when the body schema (Gallagher, 2005) pulls back from certain limbs which now become not the living medium but the alien object of the subject’s experience.

c. The boundary of this bodily ego is nevertheless given formally, not materially. Whilst the sensitive skin is an important element of the ego boundary (Anzieu, 1989), as a key juncture of the toucher and the touched (Merleau-Ponty, 1968), the ego boundary is not itself to be fundamentally identified with any physically reidentifiable particular. Its instantiation and location is instead a function of its enaction. Better conceptual analogues for the ego boundary than the material boundary provided by the skin are given by formal features such as our centre of gravity. Now if one is tempted to suppose that nouns ought to inexorably gain their meaning by referring to objects, or that the only kind of reality to be had is that enjoyed by material phenomena, then one may find oneself wanting to say that a ‘centre of gravity’ or an ‘ego boundary’ or a ‘circumference’ must be an ‘abstract object’, or is in some sense a theorist’s ‘fiction’ (cf Dennett 1992), since neither a centre of gravity or an ego boundary is in any ordinary sense an object. Nevertheless people are said to have both ego boundaries and centres of gravity; these are no more fictional entities than are people’s names – i.e. they are not fictional entities but rather non-entitative facts; and reference to them enters unproblematically into explanations of behaviour. For example we may refer to the height of a table’s centre of gravity in an explanation of why it tipped over with such alacrity (Dennett, 1992), or to the fragility of a person’s ego boundary in an explanation of why they are prone to passivity experiences, hallucinations of voices, and paranoid anxiety. So long as we decide to not mislead ourselves by reifying these phenomena we may surely offer them the latitude to enjoy their essentially formal rather than material natures. (By ‘formal’ as opposed to ‘material’ I am indicating that whilst someone’s reach, or the earth’s equator, or a table’s centre of gravity, or someone’s ego boundary, have location and (often) shape, they do not have substantial properties such as mass or density, width or height.) In this way we can confidently steer away from metaphysical, reifying, readings which would, say, literalise Freud’s (1916-17) poetic depiction of the ego as amoeba, of an ego which libidinally cathects its objects just as the amoeba reaches out to its objects with its pseudopodia, and avoid attempting to construe the grammar of ‘ego boundary’ along the lines of the grammar of ‘cell membrane’.

More helpful here to our reflective understanding of the meaning of our terms (‘ego boundary’) than Freud’s microbial poetics is I believe Merleau-Ponty’s underdeveloped yet suggestive notion, in his last working notes, of the ‘chiasm’ - which is not itself any kind of physical boundary between self and experienced other, but rather a kind of ‘fold’ or ’turning point’ or ‘frontier surface… where occurs the veering I-Other, Other-I’; or: an ‘axis alone given - the end of the finger of the glove – [that] is nothingness – but a nothingness one can turn over, and where then one sees things’ (Merleau-Ponty, 1968, p. 263). But regardless of the precise metaphor one prefers, what is central is that an ego or self boundary that is not a material wall but rather a formal demarcation between experiencing self and experienced other.

d. The ego boundary is constituted autopoietically. That is to say, the placement of the ego boundary impacts the ongoing sensori-motor activity of the organism and, in a continuous, circular, and self-maintaining manner, the environmental activity of the organism in turn impacts the placement of the ego boundary. Here ‘placement’ does not mean: correct representation of prior location, but rather: actual creation and recreation at a particular juncture. Moreover, although the creation of the ego boundary at a particular juncture goes on to affect, and is in turn affected by, the organism’s ongoing comprehending encounter with its environment, its creation and placement is not actively or intentionally contrived. Rather, it emerges autochthonously as a function of the situated sensori-motor activity of the organism.

Despite the above-mentioned disanalogies we can understand the spontaneous self-assembly of the ego boundary by comparing it in this limited respect with the formation of the cell membrane. (The enactivist Evan Thompson (2007) has argued for a deep continuity of life and mind; in this section however I am merely noting one particular analogy between cells and selves.) The cell membrane is a continuous product of the situated cell’s own ongoing activity: we meet here not with a product which is created by an exogenous production line, but rather with a production line tasked with producing itself. So too key aspects of the self-other distinction are theorized by enactivism as an emergent property of the ongoing situated sensorimotor dynamics of the organism. Furthermore, living systems not only have self-organising parts; the activity of the system itself contributes to further the functioning and integrity of that stable internal milieu which is itself conducive to further self-organisation: this is the autopoietic, bootstrapping, wonder of living form.

So too with the perceptual activity of the organism: the distinction between self and other drops out automatically of the organism’s ongoing, environmentally situated, temporally chained, moments of sensorimotor activity. Cycles of auto-calibrating sensorimotor activity make for an organism’s differentiation of itself from its environment – an environment which, to the extent that it is thus differentiated from the self, can be perceptually pulled into view. The strongest and most stable ego boundary is achieved when it is placed such that the range of my possible adaptive actions in relation to my environment is maximized. Placed too far out and too little of the world can show up for us since we cannot now be in relation to, but are simply lost in identification with, it. Placed too far in and the perceiving self becomes depleted, the body becomes desubjectivised (i.e. depersonalisation), and effective tool use becomes impossible (since the tools (e.g. cars, binoculars, tennis rackets) remain focal objects of our attention rather than taking their place within the body schema). If sensorimotor activity was not cyclic and chained, then the self-other distinction, and its corollary of a perceptual relation between self and other, could not emerge.

e. The personal / subpersonal distinction is respected. Non-enactivist cognitive scientists have often been accused of neglecting the ontological distinction between whole persons and their bodily parts (i.e. committing a mereological fallacy: Bennett & Hacker 2003). The conflation between matters ontologically subpersonal – sensory input, central processing, motor output – and matters ontologically personal – perception, thought, action – may be supported either by a hyperbolic rendering of the subpersonal (in intentionalist and representational terms) or a reductive depiction of the personal (in a manner that obscures its constitutive subjectivity, intentionality and agency). Thus a tendency to simply map action onto motor output, or perception onto sensory input, even supplementing these with central processing and ‘internal representations’, may well lead to the ignoring of, say, the significance of subpersonal elements such as motor processes in constituting the form and content of perception, or of the environment in determining the form and content of thought. By eschewing the view of mind as an inner domain of representations intervening between input and output (a conflation stigmatised by Hurley (1998) as a ‘sandwich’ picture of mind), enactivism broadens our sense of where to look for the bodily and environmental contributions to psychological form and content. Perception now becomes materially enabled by sensori-motor activity causally looping between organism and world in an ongoing sequence of self-regulating interaction. Yet because the ego’s properties are now understood formally rather than substantively, there is no need for them to be ‘identified’ as such either with states and processes inside of the head or with those in the extended extra-cranial nexus that subtends their function (contra the ‘extended mind’ thesis: Clark & Chalmers (1998)). Most relevant for present purposes, the ego boundary can now become theorized not as any pre-delimited exterior wall of the organism or the organism’s mind, but rather as an emergent autopoietically-generated axis of that entire complex weave of recursive causal processes looping not only within but also between the body and the world about it.

IV. schizophrenic disturbance of ego boundary enaction

The question now remaining is how to understand prototypical schizophrenic disturbances as disturbances of ego boundaries ‘without resorting to speculative constructions’ (Schneider 1959, p. 134). In this section, I show how an enactive perspective can offer a thoughtful theorisation of various such disturbances by understanding them as disruptions of the enactive constitution of the self, as it constantly reforms itself in contradistinction from the environment with which, and from others with whom, it interacts. The principal contention here is that, if we (ontologically) understand the organism’s subpersonal and interpersonal dynamics as enactively generating, and not merely (epistemically) as recognising, the placement of the ego boundaries, we may more safely bring in more of the first rank schizophrenic psychopathology within the scope of the notion of ego boundary disturbance. Here, then, is the enactivist proposal regarding ego boundary disturbance in schizophrenia: that it involves a formal disturbance of the equiprimordial, autopoietic and oppositional constitution of the corporeal self and its correlative perceptual cognition of its objects. What follows is the elaboration of these themes of alterity, corporeality, formality, autopoietics, and subpersonality in relation to schizophrenic boundary disturbance.

a. Schizophrenic disturbances of the ego boundary are disturbances of alterity. Cognitivist accounts of schizophrenic disturbances such as thought insertion, hearing voices, etc. are typically ‘epistemological’: they chalk schizophrenic disturbance up to a failure in the self’s autonomous recognition, within itself, of what is and what isn’t arising within (Frith, 1992). An enactivist account, by contrast, is ‘ontological’ - primary schizophrenic disturbances are of the very constitution of the self as it arises in defining contradistinction to a perceived other or perceived environment. (Pathological disturbances in one’s self-conception are, on this account, secondary to this primary disturbance.) This insight is in fact already in place in Fenichel (1937, p. 29; quoted by Frosch, 1983, p. 259): ‘In describing the nature of schizophrenia, for instance, we can just as well say that the organism “has broken with reality” as that “the ego is disrupted”… We [ - ourselves and our interlocutors - ] are two persons inasmuch as we experience ourselves in contrast to others. Owing to this relation of the ego to reality, it is only a difference in terminology whether we speak of “stages in the development of the ego” or of “stages in the development of the sense of reality”.’

Consider an ‘epistemological’ account of voice-hearing or thought insertion - i.e. one which has it that these amount to disturbances of self-awareness (Graham & Stephens, 1994; Frith, 1992). The analysis typically proceeds by promising to tease out two allegedly separable moments of phenomena such as mulling things over in foro interno - i.e. teasing out an inner voice from an inner ear, and proposing a disjunction of the two within self-awareness such that what is heard in this inner ear is no longer grasped as identical with what is produced by the inner voice. This account is not offered as the mere truism that, since no-one else is e.g. talking to the schizophrenic subject, they must be ‘talking to themselves without realising it’. Neither is it offered as a hyperbolic redescription of a purely neurological disturbance - e.g. of a failure of feedforward between areas of the brain that have been granted the monikers of ‘inner voice’ and ‘inner ear’. Instead it is intended primarily as a psychological reduction (albeit one with a possible neurological realisation) of the phenomenon of voice hearing: the schizophrenic subject is seen as making a kind of mistaken inference: I am not aware of being the author of this piece of inner mulling, therefore it must be ego alien. The promise of such accounts is their apparent ability to make the hallucinatory subject humanly intelligible to us. The cost however is significant: not only do they risk making profound psychopathology too apparently tractable (thereby missing the radical derangement of the psychotic music - and in this sense precisely not offering it recognition), but also they appear to do so at the cost of introducing a schizoid split (of now merely contingently related inner voice and inner ear) into the heart of the unity of ordinary selfhood.

An enactivist account of voices and inserted thoughts may instead insist that the phenomena truly are ego alien - not, obviously, in so far as they originate with someone else, but rather - in so far as they are constituted ab initio as non-ego. The schizophrenic subject does not walk down a wrong path; rather they lay down in walking a path manqué, or may fail (in ‘syncretistic’ or undifferentiated selfhood) to lay down a path at all (Merleau-Ponty, 1964, p. 134). We may think of this path as being in the wrong place to the extent that the delusional hallucinator is wrong to think, if she does, that others are talking to her. But the disturbance is in fact more profound than this normative talk of ‘wrongness’ can capture: the very self of such a subject is genuinely disturbed and its form is incommensurable with what otherwise would be the complementary and mutually regulating, constraining and entraining self-other enactions of other subjects. An enactive account accordingly does not take for granted the boundedness of the self as given prior or posterior to experience, nor view the fundamental interpersonal encounter as one of recognising (say) the hate or hurt within one’s own distinctly pre-constituted self, or one of inferring (say) the hate or hurt within the distinctly comprehendible self of the other. Instead it views the self-boundary as itself continually reconstituted in such encounters, and as equiprimordial in its constitution with the active (speaking) and receptive (listening) phenomena for which it provides the chiasmatic axis. On this account we do not therefore do well to talk of the schizophrenic as mistaking what is really a denizen of their own subjectivity for a citizen of another’s mind, since it is precisely the actual unity of their subjectivity which is itself compromised. Accordingly, no psychological reduction of the psychotic phenomena is possible. Yet rather than this result being seen as a failing of the enactive proposition regarding psychosis, it can instead be seen as of a piece with its recognition of the depth of the assault on selfhood made by the schizophrenic process.

b. Schizophrenic disturbances are at root disturbances of corporeal selfhood. Enactivists understand the most foundational stratum of the self, in which all others are rooted, as sensori-motor (Thompson, 2007, ch. 9). On this account, stable perceptual experience emerges as the organism keeps track of how sensory stimulation varies with bodily movement. Stable selfhood is the corollary of this, since bodily selfhood and sensori-motor experience co-emerge. With this in mind it is notable that both gross and subtle disturbances in sensorimotor selfhood are manifest in schizophrenia. Motor abnormalities can be seen in the childhoods of some who go on to develop schizophrenic psychosis (Schiffman et al., 2009). Perfect vision and blindness protect against schizophrenia, but less perfect vision, where subtle aspects of seeing self and visual other are not so easily and consistently distinguished, would appear to provide a more fertile soil for the psychosis (Landgraf & Oxterheider, 2013). And schizophrenic persons often describe disturbed bodily experiences - such as feeling their body to be dead, feeling their limbs are controlled, suffering coenaesthopathic hallucinations (e.g. of spirits writhing in their torso, or ‘energies’ coursing through their veins) and autoscopies (whole or partial out of body experiences) (Priebe & Röhricht, 2001). These can readily be understood as transient distortions of the body schema (Gallagher, 2005), such that the normal ability of the body schema to seamlessly update itself as the organism finds itself in one and then another internal and environmental configuration is compromised. Now the total body no longer remains a purely ‘transparent’ ‘from-where’ of experience, nor a domain in which those healthy vitality affects that arise from feelings of transient subtle non-self-coincidence obtain, but at times becomes in part a grossly disturbed object to such other parts of it which do still constitute the corporeal subject (de Haan & Fuchs, 2010). Against such a backdrop of terrifying compromise to the continuous stable reformation of the body schema, it is not surprising that schizophrenic persons may opt instead for the relative balm of catatonia or withdrawal (Corin & Lauzon, 1992).

c. Ego boundary disturbance amounts to idiosyncratic constitution of the chiasm. As described above, ‘ego boundary’ is a formal concept: it is not a boundary constituted of anything material, psychological or spiritual, but instead a ‘nothingness’, an outer frontier of the self, an endlessly reformed axis where Other begins and I end, a necessary ‘veering’ point without which everyday experience of otherness would be impossible (Merleau-Ponty, 1968, p. 263). This is phenomenologically accurate: one no more encounters an ego boundary than one encounters the edge of one’s visual field. It is not like the substantial black circle around the white space in the centre of the letter O that keeps the white within away from the white of the page, but rather is akin to the insubstantial edge of the black and the white. So too, ego boundary disturbance in schizophrenia is not something witnessed directly by the psychotic subject: rather one experiences the consequences of its perturbations. Whilst it is true that schizophrenia sufferers may reflect on the instability and idiosyncrasy of their self/other demarcations, and the literature contains many compelling examples of this (Sass & Parnas 2003; Scharfetter 1995), the fundamental disturbance is not itself something given to experience, but is rather of an essential condition of the possibility of coherent experience itself (hence to a ‘transcendental’ aspect of the ego). The primary sense in which a subject experiences ego boundary disturbance is accordingly that of suffering or undergoing, rather than perceiving, it. By analogy: nobody, schizophrenic or otherwise, can witness the edge of their visual field, since the edge just is itself the limit of any witnessing rather than something witnessed. Yet if the edge of someone’s visual field alters they will suffer deformations in their perceptual experience, and the fact of such alterations will – especially if they are fluctuating – naturally become preoccupying for such a sufferer.

Formulating the ego boundary enactively provides a further clue to understanding those aspects of schizophrenic psychopathology that have to do with transitivism and appersonation - i.e. cases in which aspects of self and other switch place in the schizophrenic’s experience. The only psychology to really theorise such phenomena is psychoanalytic; it formulates them in terms of unconsciously motivated processes of introjective and projective identification (Freeman 1976). What that psychology doesn’t do however is to explain how the mind is so structured as to make such massively distorting dynamic processes possible.

An enactivist approach helps articulate the conditions of possibility for transitivism. Consider that, for an enactivist, the task of experience is not one of accurately carrying a representation of an outer object into an already delineated internal milieu. Instead it is one of coming into an ongoing potentially active relation with this object – a relation in which the two (self, experienced object) poles of the perceptual encounter, and the delineation of the zone of their abutting, continuously redevelop. To retain invariant ego characteristics when the physical position of person and object is in transformation requires considerable neurodynamic sophistication. Such invariance in the ego is correlative with that invariance (in the perception of the object) across transformations (of sensory stimulation – as movement of the body or of the object impacts on sensory stimulation) which makes for any coherent experience at all (Gibson, 1965). Thus if we see an object moving towards us we do not, if all is going well, experience it as increasing in size, nor correlatively experience ourselves as diminishing in size or as moving toward it.

In this constitutive unfolding of the ego-other relation it is normal for the ego pole to constitute at the locus of the physical body, and for the ongoing constitution of the ego-other distinction to be somewhat constrained by prior ego syntheses (a function called ‘protention’ by Husserl; see Gallagher 2006, ch. 8) and also by the complementary and constraining shapes of ego-other constitution brought by those others with whom one interacts. When the body schema becomes fragile, however, or when one is cut off from others, or is in relations with others who are experienced – in what they offer by way of ego-constituting affordances – as unsettling to the stable constitution of the self, the constitution of this or that aspect of the ego-other dyad can become solved for in unexpected ways. Thus the ego pole of the ego-other relation now may be transiently constituted at the locus of what others would describe as the body of the other. And when the stability of the ego-other dyad is compromised and fragile in such ways, the potential for dynamic motivational factors (projective and introjective identification) to exploit the vulnerability will be proportionately greater.

d. Schizophrenic disturbances arise from autopoietic disturbances. The stability of the ego boundary that emerges spontaneously and in a self-organising manner out of the coupling of lived body and world (including others) can clearly be thwarted. Consider for example the classic ‘double bind’ predicaments elaborated by Bateson et al (1973) - in which someone is repeatedly invited into relational moments which embed complex contradictory messages (you are loved / you are not loved). Or cases of emotional manipulation in which we are tacitly invited by someone to carry more than our fair share of a moral burden for an interpersonal disturbance (i.e. we are subject to someone’s ‘projective identification’ or, in the more popular idiom, to their ‘gaslighting’). Self boundaries usually crystallise automatically within the nexus of interpersonal and self-world interactions: they form part of the spontaneously emerging background framework structuring our everyday understanding. If all goes well corporeally and socially, the boundaries that we form are complementary with those formed by others and with a maximal grip on our proximal environment. But, without taking a stand on empirical issues here, it is at least readily intelligible to us how, under the prolonged strain of either a disturbed body schema or of others’ projective manipulations, that normally tacit autopoietic process of ego boundary enactment can be disturbed. For example, in the complex weave of emotional interactions between parent and teenager, the question of who is to blame for what in a difficult conversation, of ‘who started it’, of what is and is not reasonable, will constantly need to be negotiated. The individuation of the ego is at its most intense during adolescence, and so the parent must not only offer a stable non-self-contradictory opportunity for their child’s consistent complementary ego enaction, but also be able to take more than a 50% share of the burden of tolerating and thinking through the difficulties arising in that relationship. A strong and stable ego emerges out of such consistent affordances for ego enaction. If however the teenager’s ego-other enactions meet with little recognition, or are sometimes invited yet then again rejected, or are consistently perverted by a parent who projects unwanted emotions into the teenager, the automatic emergent constitution of a stable self will be thwarted, and the project of individuation will accordingly be intensified and, in some circumstances, derailed. As is well known, schizophrenic disturbances are most likely to emerge in the late teenage years (Harrop & Trower, 2003), and psychotic breaks are more likely in those living in families marked by patterns of unsettling and intrusive emotional interaction (Read, Seymour & Mosher, 2004).

e. Respecting the personal / subpersonal distinction. A cognitivist approach promises what on reflection is a rather too happy solution to the problem of (how to understand) hallucination: hallucinations are seen as inner representational brain states that either fail to reflect the reality of the external situation or obtain in the absence of an awareness of their internal generation. In fact on certain cognitivist, internalist, theorisations of experience the hallucinatory situation is just a bad case of a more general epistemological nightmare in which we are only ever really directly acquainted with our inner experiences and so can never enjoy direct epistemic contact with our external situation (cf Frith, 1992; Frith, 2007; Gipps, 2009). The risks of such a formulation of the perceptual act are well-known: not only that we court insurmountable skepticism, but that we tacitly take for granted rather than actually theorise the formation and delineation of the self and the very phenomenon of the perceptual presence to a self of an object (Olafson 2001). This may be bolstered by a failure to treat carefully such notions such as ‘representation’ or ‘information’ such that an unwitting slippage occurs between subpersonal and personal registers (Bennett & Hacker 2003); a psychological sense of ‘the inner’ is then simply mapped without explanation onto what is physically inside the skull, or we are offered a mere schematic of inner pictures arising in a proper causal manner (in perception) or improperly (in hallucination), with no explication of who is there to witness these pictures (perhaps apart from a mythical homunculus; cf Kenny, 1971).

The enactivist’s theorization of perceptual presence invokes no internal representations and takes for granted no pre-delimited experiencing ego. It does not offer us a psychological ‘error theory’ of hallucination and delusional perception; that is, it does not fall into the trap of trying to render psychologically explicable why the schizophrenic person so much as takes herself to see what actually she cannot. Instead it considers the entire nexus of ‘loopy’, re-entrant biological and physical processes sustaining and subtending the person’s relationship with the objects around her. Out of this entire environment-sensori-CNS-motor-environment nexus of feedback loops emerge the poles of experiencing subject and experienced object organized around the axis of the ego boundary. Those mere illusions of true perception known as hallucinations emerge by contrast involve, at the subpersonal level, situations in which the neurophysiological feedback loops do not extend adequately beyond the body. What would once have been constituted as the medium of thought now becomes constituted as the objects to which a world-retreated subject is equiprimordially constituted as being in relation – thus hallucinations of voices and made thoughts. Aspects of what would once have been the living medium of agency – the animate body – now becomes constituted as foreign – hence made actions and coenaesthopathies. Or, when the ego boundary axis of one’s relation to reality emerges too far out, delusional experiences emerge – in which objects beyond are incorporated into an extended version of the body schema, giving rise to delusions of environmental control. No firm axis obtains for the clear distinction of self and other – hence thought diffusion or broadcast and delusions of transparency.

In sum, by theorizing ego constitution in enactive terms we see how its transcendental (experience-structuring) aspects become amenable to naturalistic analysis, and also how a wider range of first-rank symptoms become intelligible as ego boundary disturbances than is apparent on any merely epistemic treatment of these difficulties.

V. therapeutic implications

If we are right to think that a disturbance in ego boundary enaction is a core underlying psychopathologic motor of distinctly schizophrenic psychopathology, then it will be important to direct considerable therapeutic attention to the stabilising of such boundaries. Below I consider how aspects of the work of various extant therapies can be theorised in enactive terms. Such an approach, I suggest, offers the hope of a genuinely coherent and comprehensive integration of what may otherwise appear incommensurable therapeutic models.

Body psychotherapy: An awareness of the effect of disturbed enaction of sensori-motor selfhood on schizophrenic psychopathology and its significance for therapeutic interaction has been significant in dance-movement and body psychotherapies at least since the work of Schoop (May et al. 1963; Goertzel et al. 1965, Schoop 1974). Cogent argument for the applicability of body psychotherapy to stabilise the corporeal ego in schizophrenia has been made by Scharfetter (1999), and the method and promising preliminary therapeutic results have been documented by Röhricht et al (2009). Group-conducted interventions may include self-massage and exploration of the bodily boundary extending into a physical investigation of the personal kineasphere and shared space, simple interaction with simple objects, intercorporeal communication (e.g. patients rolling a ball to one another with an emphasis on the distinct identities of the participants), grounding exercises and somatosensory awareness training, wrapping oneself in cloths, interaction with others to explore peripersonal spatial boundaries, etc. These are not to be understood as mere physical exercises, but as intrinsically emotionally-charged interactions concerned with developing the confidence to allow others into one’s ‘space’ without fear of engulfment, intrusion or collapse, or the confidence to define and protect one’s ‘space’ against the relatively forceful presence of others. The relevance of these interactions for the stable and intercorporeally commensurable demarcation of the corporeal ego should be obvious. In fact, by drawing on a contrast between an underlying, necessarily un-experienced (but instead experience-structuring or ‘transcendental’) body schema and an experienced (empirical) body image, and locating the core disturbance in the former, enactivism offers to the bodywork therapist the suggestion that disturbances in the body image may be epiphenomenal to disturbances in the body schema, and hence possibly less significant as loci of intervention.

Family therapy: Ever since it became known that emotional intrusiveness, over-involvement, criticism, rejection, relational attempts to put individual round pegs in familial square holes, and communicational deviance in the family predicts onset (Goldstein, 1987) and relapse (Kavanagh, 1992) of schizophrenic psychosis, the idea of family therapy in particular cases makes manifest sense. An enactivist conception of ego boundary formation and maintenance theorises this nicely: the enactive formation of Jill’s ego occurs in complementary conjunction with that of Jack, and if the opportunities for complementary ego enaction made available to Jill by Jack are radically constrained then Jill’s ego boundaries risk being bent out of the shape which they would otherwise take. Angry and critical chains of interactions occur when there are uncomplementary forms of ego boundary enaction: Jack, for example, attempting to locate moral responsibility for interactional ills in Jill which Jill would rather locate in Jack. There are now several different forms of family therapy all designed to enhance clear mutual understanding and stress management, and to reduce criticism, intrusiveness and over-protection between members of a family in which someone has been diagnosed with schizophrenia (Aderhold & Gottwalz, 2004). An enactivist theorisation as described above allows for their unification.

Dialogical psychotherapy: This paper has largely considered the corporeal foundation of selfhood. Yet much of what is interwoven with and sits on top of this corporeal foundation, and which elaborates the distinctly human form of selfhood, is linguistic. To acknowledge the significance of language is not to say that self-enaction is primarily reflective, self-conscious or insight-driven. As Paul and John Lysaker (2008) describe in their dialogical conception of selfhood, our ‘sense of self emerges out of an interaction among self-positions [which] positions are axes of self–world interaction, more a matter of who we are, than of whom we take ourselves to be.’ The Lysakers’ dialogical theory is in fact enactive: important aspects of selfhood are conceived by them as unreflectively constituted and reinforced in and through our verbal interactions, rather than preceding such interactions as their self-sustaining inwardly-cognisable source.

On the basis of their theory of the dialogical self the Lysakers offer us their conception of schizophrenia as self-disturbance and of its apt psychotherapy. For patients whose difficulties in integrated self-enaction result in a retreat to a stereotyped rehearsal of a monothematic delusional story and a correlative loss of a sense of the diversity of the forms of their personal agency, the recommended therapy involves supporting the cultivation of an ability to acknowledge and take ownership of emotional experience, in part through the form of the therapist’s address (‘You find you can only think of…’). In this way the therapist offers recognition to the patient of their subjectivity in a form gradually assimilable by the patient herself; later he encourages the animation of further self-positions enacted by the patient in the diverse arenas of her life. For patients with a simple dearth of self-enaction the therapist’s repeated focus is on offering recognition to whatever self-positions are being verbally enacted. Sometimes such enaction unfolds more readily when the focus is, as with play therapy, at first more oblique - for example the patient may first explore the possible experience of the therapist before they are able to voice their own. And for thought-disordered patients who shift chaotically between fragmented self-positions and who may struggle to own their experience, the focus is on strengthening such ownership, perhaps through offering recognition in the form of frequent and clear ‘You are…[angry, feeling hurt, etc.]’ statements.

Psychoanalytic psychotherapy: Of all the therapies it is psychoanalysis which has most closely investigated the ways in which patients can lose or jettison what would otherwise be parts of themselves through introjective and projective identification with others. (In what follows I read what is valuable in the psychoanalytic vision out of what is philosophically problematic in the metapsychology – i.e. in the reified talk of libido, cathexis, egos, ego boundaries etc. – cf section ii..) In these ways the patient with a weak ego metabolises external threats to ego coherence through incorporating what would typically have been enactively grasped as external instead within the scope of their ego, or disowns, by ‘evacuating’ into an other, parts of the self that threaten to overwhelm and thereby enacts a correlatively depleted self. The subtle verbal and non-verbal behaviours through which such enactions obtain, and their typical resonance in the therapist’s countertransference, are now well-documented in the literature (Spillius & O’Shaughnessy 2011). The purpose of therapy conducted with sensitivity to such motivated disturbances of ego boundary enaction is not for the therapist to simply resist and return the patient’s projections. After all, the psychoanalytic understanding is that projective and introjective defences function to ameliorate the current terrifying experience of ego disturbance (although the defences may unwittingly make things worse in the long term). Instead, partly through a careful consultation of their countertransference, the therapist’s job is to understand what painful feelings would be arising for the patient were their ego boundary to be enacted in such a position as to include such affects within the ego. In this way the therapist and patient can come to co-digest, make bearable and thinkable, the emotional experience in question.

One of the strengths of therapies such as those listed above, therapies which work to support the enaction of stable ego boundaries in the schizophrenia sufferer, is that effectively they target (what on the enactivist theorization offered here is understood as) the core ego pathology at the root of much of the symptomatology. What we arrive at is a unified psychopathological scheme that exemplifies the validity on the diagnosis and provides a clear remit for therapeutic intervention. This remit also helps us avoid the pitfalls of therapies which serve to merely foster cognitive insight, target individual symptoms rather than the psychogenic origins of such symptoms, miss the depth of the schizophrenic self-disturbances, and risk making matters worse by removing such symptoms as serve anxiolytic functions (e.g. those delusions that make the terror of ego-dissolution more bearable by thematising it into comprehendible frightening persecution by external agencies) before having stabilized the ego.

VI. conclusion

Without an organising concept of ego disturbance in general, and ego boundary disturbance in particular, the diagnosis of schizophrenia threatens to fall apart into a mere construct – and one with little apparent validity. Yet without a naturalistically adequate conceptual framework for understanding the ego (self), ego boundaries and ego boundary disturbance, such notions in turn can appear unhelpfully recondite. In this paper I have suggested that enactivism provides such a framework, rendering naturalistically explicable schizophrenic disturbances to the transcendental structure of the ego. The pitfalls of nosologically-trivializing ‘positivist’ schemes which ignore core ego disturbances in their focus on mere symptoms, of insufficiently deep ‘epistemological’ treatments which consider only self-knowledge rather than selfhood, and of obscurantist ‘metaphysical’ theorizations of the ego boundary that make its structure and disturbances naturalistically inexplicable, may thereby be avoided. And whilst such an enactivist theory is of course distal to the therapeutic endeavor, it yet serves to rationalize the coherent provision of a variety of treatments and directs their attention to core, rather than merely peripheral, aspects of the psychotic process.

Other benefits of an enactivist framework for thinking about schizophrenia remain to be reaped. As mentioned, the ego boundary is but one aspect of the ego that becomes disturbed in schizophrenia; Scharfetter’s (1995) scheme also points us to disturbances in ego vitality, identity, consistency and activity. The ways in which these are constitutively and causally inter-related must yet be elaborated. Further, enactivism offers us ways of thinking about causation across levels in systems which include both sub-personal bottom-up and intentionality-replete top-down elements in mutually informing interaction (Thompson 2007, ch. 3 and Appendix B). And that in turn provides us with significant clues as how to understand the relationship between neurological, psychological and family systems in schizophrenia (de Haan, ****) - for example, of how not only the content but also the formal aspect of hallucinated voices may relate to disturbances of ego enaction in a familial context. That, however, is all a story for another day.

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