J SP

Being Interrupted:
The Self and Schizophrenia
JOHN LYSAKER
University of Oregon

PAUL LYSAKER
Roudebush VA Medical Center, Indianapolis, IN; and
The Indiana University School of Medicine
2 JOHN LYSAKER AND PAUL LYSAKER

ogy, self-conscious and prereflective awareness of bodily states, and so forth.

Nor are we claiming that one might develop a comprehensive account using
only the elements that we employ, nor even that these elements are irreducible
to other phenomena. Falliblists through and through, we have little interest in
dictating what any account simply must say at the end of inquiry.
In order to demonstrate the power of a dialogical theory of the self, we
will use it to interpret the phenomenon of schizophrenia, and in a way that pre-
serves the participants' perspective, addressing what it is like to suffer from
schizophrenia and what it means when persons with schizophrenia tell us that
their sense of self has been fundamentally damaged or disrupted. More specifi-
cally, we will interpret the disruptions in sense of self that characterize schizo-
phrenia as well as the persistence of various symptoms associated with
schizophrenia, particularly: (a) hallucinations (or having sensory perceptions
that others do not share); (b) delusions (or having beliefs that others deem idio-
syncratic and grossly implausible); and finally (c) the diminishment of will and
desire. This will show, we think, that a dialogical approach to philosophical
anthropology, clinical and experimental psychological research, and psycho-
therapy promises to pay rich dividends.
Let's begin with something of an intellectual history of dialogical theory.
The outlines of a dialogical conception of the self can be found in diverse places.
Among a distinguished group, we find Bakhtin's reading of Dostoyevsky,
Nietzsche's reflections on subjectivity, and Dewey's and Mead's social psy-
chology particularly helpful. Interpreting the poetics of Dostoyevsky, Bakhtin
(1985) asserts that humans are best described as polyphonic beings, products of
an ongoing series of dialogues among distinct voices. Rather than revolving
around singular, conclusive perspectives, Bakhtin holds that our sense of self
emerges through conversations among functionally independent elements within
persons. As an illustration, consider Dostoyevsky's description of Roskolnikov
in Crime and Punishment: "sullen, gloomy, arrogant, proud ... insecure ...mag-
nanimous and kind ... cold and callous ... always in a hurry, always too busy
and yet he lies there doing nothing" (Dostoyevsky 1993, 215). The point is not
that these are contradictory modes of a singular character, but that Roskolnikov's
character is an evolving movement among complementary, contrary, and even
contradictory facets.
An admirer of Dostoyevsky's psychological insights, Nietzsche also de-
scribes the self as a "subjective multiplicity." He argues that the self is best
described as a "common wealth" or "a social structure composed of many souls"
(1966, 26), offering the analogy that one person no more contains a singular self
than Great Britain is a singular person. While the self and Britain may define
themselves by certain events (e.g., a job or colonial holdings), both are com-
posed of disparate elements that cannot be synthesized without remainder. At
base, the claim is phenomenological. When observing one's feelings, thoughts,
BEING INTERRUPTED 3

and behavior, one does not find a singular entity, but an ensemble of disposi-
tions (self-as-assertive, self-as-shy) and roles (self-as-executive, self-as-gun-
collector) that often seem disconnected from or even at odds with one another.
In its origins, then, dialogical theory offers a self that is a complex en-
semble of interanimating parts whose interactions are not driven by an
overarching ego. Recently, Nietzsche's and Bakhtin's view has been taken up
and subjected to more systematic inquiry, and their notion of a multiplicity of
souls has been cast in terms of multiple self-positions, e.g., self-as-brother or
self-as-anxious. Hermans alone (1996a; 1996b) and with colleagues (Hermans,
Rijks, and Kempen 1993) has studied internal dialogue as manifest in structured
interviews and concluded that self-coherence is maintained through interactions
between self-positions or voices that are not centrally integrated. Analyzing in-
dividual patterns of verbalized self-presentation, Hermans suggests that dialogue
is made possible by a temporary hierarchical arrangement of self-positions that
periodically and spontaneously realigns itself with dominant self-positions re-
treating into the background and previously nondominant self-positions coming
to the forefront. For example, suppose one is teaching a night class in a continu-
ing education program, and one's therapist enrolls. In the classroom, self-as-
teacher will have to come to the fore whereas self-as-client will have to recede,
and vice versa during sessions. Or, in order not to be a pedantic nuisance, a
professor will need to move from self-as-educator to self-as-neighbor in order
to establish friendships on her or his block. According to Hermans and his coau-
thors, it is precisely movement among and between disparate positions that in-
tegrates our sense of self.
Using semi-structured interviews Gregg (1995) also observes that an ex-
perience of self-coherence results from regular shifts within self-awareness. His
focus, however, concerns the "places" that might allow such shifts to occur,
labeling them "multistable or structurally ambiguous" symbols (617). For ex-
ample, a self-position like "diamond in the rough" could be a multistable sym-
bol that allows one to move among differing self-descriptions such as "crude,"
"dirty," "precious," and "refined." The point is not that "diamond in the rough"
absorbs these self-descriptions. Rather, like Bakhtin, Gregg holds that the self is
a matter of movement and negotiation among characteristics. He thus regards
these multistable symbols as narratival elements that enable and sustain move-
ment and negotiation.
Although our terminology differs from Gregg's, we read these multistable
symbols as self-positions in their own right. Our reasoning begins with a phe-
nomenological reconstruction. Across one's life, various self-positions interact
with one another, thus creating opportunities for generalizations about one's life
with regard to those positions. (As we will see later, life histories and their gen-
eralizations are generated from their own self-positions and are thus dialogical
as well.) If, for example, one performs well in a variety of social roles (say
4 JOHN LYSAKER AND PAUL LYSAKER

student, athlete, and piano player), one may come to regard oneself as a "suc-
cess." Life histories gather around many such symbols, however. Thus one si-
multaneously may regard oneself as a success, as lonely, as a coward, etc., and
these symbols can no doubt come into contact and conflict with one another. For
example, one's sense of self-as-success, when confronted with self-as-lonely,
may shrink in scope, leaving one as self-as-success with regard to solo activities
but self-as-failure with regard to social ones. Second, as time passes, multistable
symbols will have to engage emergent self-positions, e.g., self-as-parent. Given
this possibility of dialogue among multistable symbols, and dialogue between
existent multistable symbols and emergent self-positions, we think it reason-
able also to regard these integrating symbols as self-positions, as aspects of the
self that belong to and participate in (rather than reign over) an ensemble of
positions among which one continually moves.
While the multistable symbols Gregg locates may be regarded as self-
positions, they are self-positions of a special sort: they directly refer to other
self-positions. Unlike self-positions such as self-as-brother or self-as-student,
self-as-success arises through an explicit synthesis of other self-positions. True,
self-as-brother implicates other positions, e.g., self-as-son, but playing that role
does not require one explicitly to take up being a son. Self-as-success, however,
is explicitly concerned with those positions wherein one has met with success.
Given the presence of multistable symbols that nevertheless can function
as self-positions in their own right, it seems justifiable to distinguish two kinds
of self-position: "first-order-positions" and "metapositions." We speak of posi-
tions like self-as-author as "first-order" because they operate within our lives in
nonreflexive manners. Other positions, such as self-as-failure, are in part tied to
reflexive acts, however, and thus we term them "metapositions," albeit only in a
grammatical sense. The point is not that metapositions reflect the insight or
activity of a self that floats above the many self-positions whose negotiation we
are. Rather, such self-positions are metapositions because they concern how
one should regard other self-positions, much as metaphilosophy concerns how
one should regard philosophy.
Our protestations to the contrary, one might still expect to find an inte-
grating author at the core of dialogical activity, particularly with regard to
metapositions. We see no reason to suppose this. As Hume argues, we have no
knowledge of ourselves as having any "perfect identity and simplicity" (1888,
251). He continues: "I never catch myself at any time without a perception, and
never can observe any thing but the perception.... I may venture to affirm of the
rest of mankind, that they are nothing but a bundle or collection of perceptions,
which succeed each other with an inconceivable rapidity, and are in a perpetual
flux and movement" (252). True, acts like perception and desire are grammati-
cally referred to subjects who perceive, desire, etc., but reflection suggests that
such reference is specious with regard to any substantial entity. As Emerson
writes in "The Oversoul," "Man is a stream whose source is hidden. Our being
BEING INTERRUPTED 5

is descending into us from we know not whence" (Porte and Morris 2001, 163).
Once again, the claim is phenomenological, and in a manner freed from the kind
of grammar-driven arguments that often lead one to grope about for a transcen-
dental ego. Thoughts, feelings, and even the insights that form the basis of
metapositions, as they are given or disclosed, come to us rather than respond to
our summons, and without any attendant apparent author. As Emerson states in
"The Method of Nature," " I conceive of man [sic] as always spoken to from
behind and unable to turn his head and see the speaker" (87).
Now, in the context of an account of the self, one mustn't be misled by a
prevailing obsession with the epistemic subject and regard self-positions prima-
rily in terms of representations or even propositional attitudes, as if they were
the fruits of a reflexive act of self-interpretation and best understood as judg-
ments about the self. First, judgments about the self are parasitic upon first-
order self-positions, for those in part constitute the self being judged. One can
see this in metapositions. One is a self-as-failure only in reference to first-order
positions that one enacts poorly. One might say, twisting Hume a bit, that one
never finds oneself without a self-position. Second, and this we will argue in
more detail shortly, no self-position is disconnected from desire and activity.
Self-positions are thus not merely a matter of how we perceive ourselves, but
also of what and how we are.
In place of Hume's bundle of perceptions, then, we would rather speak of
a bundle of habits, agreeing with Dewey that "All habits are demands for certain
kinds of activity; and they constitute the self" (1988, 21). We are drawn to em-
ploying a language of habits for several reasons. First, the language of habit
captures the prereflective nature of most human activity, from walking to shak-
ing hands. Even movement among self-positions seems to occur without self-
conscious choice. When walking down the street in a foreign city, for example,
I inhabit the role of tourist, most likely behaving in ways that do not call atten-
tion to myself. If I suddenly and unexpectedly see a friend, however, I'll begin
to wave and smile, and act as a "friend," and all without having "decided" to
leave self-as-tourist behind in favor of self-as-friend. The point, then, is that for
the most part, we live on autopilot. As Nietzsche writes, "For we could think,
feel, will, and remember, and we could also `act' in every sense of the word, and
yet none of all this would have to `enter our consciousness' (as one says meta-
phorically)" (1974, 297). Now, one may find Nietzsche's remark exaggerated.
We, however, do not. Athletic and musical performances involve extremely com-
plex behaviors. But as many have testified, the self-conscious election of move-
ments or actions, even in virtuoso performance, is not only not required, but
often a hindrance. It would appear, then, that inhabiting and moving among
self-positions occurs prereflectively, and drives the self in a habitual manner.
The language of habits also merges self-positions with desire and activ-
ity, thus clarifying how self-positions function in human behavior. Consider, for
example, the habit of gambling. Self-as-gambler marks a set of capacities (I
6 JOHN LYSAKER AND PAUL LYSAKER

know how to gamble), a set of desires (I seek the ends associated with gam-
bling, even if not wholeheartedly), and an objective tendency to engage in those
activities. Or, consider the self in an affective and metapositional manner. Self-
as-angry marks a set of capacities (e.g., to yell, seek revenge, interfere, etc.),
desires (e.g., to frighten, to harm, to undermine, to release steam), and an objec-
tive tendency to get angry. On our view, then, self-positions are bound to moti-
vation and action, more a matter of the pragmatics of subjectivity than of their
propositional content concerning oneself. And it is principally because self-po-
sitions are bound to what Dewey terms an "inherent tendency to action" that we
regard them as habits.
It is perhaps worth stressing that not only first-order self-positions oper-
ate habitually. Metapositions are habitual as well. While the position of self-as-
success may emerge in a reflective moment, it need not remain merely reflective.
In the spirit of James's "The Will to Believe," and as much self-esteem research
suggests, positive self-regard may lead one to try new and novel things, that is,
it too is tied to a disposition to act in certain ways. For example, the metaposition
self-as-success would involve a range of activities in which one has been and
expects to be successful (e.g., playing the harmonica, learning languages, or
more generally, just doing things), some desires (i.e., to continue to succeed in
whatever one does), and a disposition to act in certain ways, e.g., to take risks
(or one might come to fear failure and thus keep to those activities in which one
has been successful).'
Our final reason for regarding self-positions as habits involves the way in
which the concept "habit" draws self-positions outside a pure interiority. Bound
to rhetoric of representation, self-interpretation, and even self-perception, self-
positions remain mere ideas we have about ourselves. Once self-positions are
construed along the lines of habits, however, the capacities they involve are
bound to the worldly scenarios that solicit and sustain them. The self-position
self-as-gambler will not arise unless there are situations in which one can gamble.
Likewise, the self-position self-as-melancholic will not arise unless loss, death,
and the passage of time are in some sense there for one to dwell upon. We thus
agree with Dewey that habits and thereby self-positions "may be profitably com-
pared to physiological functions like breathing, digesting. The latter are, to be
sure, involuntary, while habits are acquired. But ... habits are like functions ...
in requiring the cooperation of organism and environment" (Dewey 1988, 15).
Now, one should not construe a habit's cooperation with its environment
in epistemically secure terms, as if grounding in a habit ensured that self-posi-
tions were predicated on reliable, prereflective knowledge of the world. Such an
inference would not only be wrong, it would miss the point and risk ensnaring
us once again in an epistemic frame. Rather than championing a kind of animal
faith at the root of self-positions, our point concerns the dependency of habits
on worldly relations, one that renders them transactional, the feature of a being
whose life is structurally bound to and reflects engagements with a surrounding
BEING INTERRUPTED 7

world. Even delusional self-positions, e.g., self-as-alien, are tied to scenarios

within which they are enacted, e.g., a distant planet, a space ship, persecution by
the CIA, etc. Thus rather than securing the veracity of those beliefs concerning
the world that are correlates of self-positions, thinking of self-positions in terms
of habits performs a more general service. It brings them out into the world such
that any given self-position is a function of and a contributing force to a thor-
oughly relational phenomenon, i.e., human being.
It is crucial to maintain a relational conception of the dialogical self be-
cause dialogue is not simply an internal event but an interpersonal one as well.
Said otherwise, one's internal polyphony develops and moves in response to
social demands. As Emerson writes, "What do we not owe to the call which
society makes upon the slumbering abilities of each individual?" (Whicher 1964,
18). First, first-order self-positions are bound to social roles like student, sib-
ling, or parking lot attendant? We speak of "social roles" here for several rea-
sons. Individuals do not create these positions, but inherit them. Moreover, the
community at large distinguishes them from other positions in ways that are
normatively binding in a loose sense (e.g., studying is normally not part of be-
ing a parking lot attendant and being related by blood is not required to be a
fellow student). Positions like that of student are thus not only socially gener-
ated, but what is generated amounts to a cluster of practices, expected behav-
iors, and outcomes, the performance of which involves discernable social actions,
e.g., enrolling in and possibly attending classes, satisfying requirements, and
graduating. And as we have already intimated, multistable metapositions are
implicitly and often explicitly tied to social roles. One is a diamond in the rough
or a success with reference to things one could become or one already is, e.g., a
good partner or a reliable colleague. Or, one is destructive in contexts that one
destroys, e.g., romantic relationships and family gatherings, and in a particular
role, e.g., as a lover or an in-law. Second, metapositions are often generated
from the standpoint of particular social roles. The self-position diamond-in-the-
rough might arise for a self-in-therapy, or a larger, more complex life history
involving several metapositions might be told from the standpoint of self-as-
autobiographer.
While constitutive of the self, social roles are nevertheless personal, or
better still, personalized. If only for survival's sake, social roles must be indi-
viduated by those who play them. I may be a carnivore but learn to avoid certain
meats that upset my stomach. Also, through interaction with other self-posi-
tions, social roles cannot help but be personalized, e.g., an orphan with siblings
is adopted into a family without children that later becomes wealthy. These chang-
ing circumstances will individuate the manner in which she is a "daughter." She
begins as daughter/sibling-as-orphan, then daughter/sibling-as-orphan/adopted-
only-child, then daughter/sibling-as-orphan/adopted-only-child/heir-to-a-fortune.
Thus, while self-positions are bound to social roles, their relation is a true rela-
tion and not a unidirectional process of construction.
8 JOHN LYSAKER AND PAUL LYSAKER

At this point, a certain degree of readerly exasperation may be mounting:

"You invoke notions like life histories, and still you deny the presence of an
authorial ego amid manifold self-positions. Where's the sense in that?" In order
to clarify our resistance to the expectation that informs this kind of frustration,
let us return to an earlier point. Following Hume and Nietzsche, we see nothing
beyond a grammar-led prejudice at the core of an insistence on the need for a
transcendent ego reigning over self-positions.' Still, it is reasonable to ask how
we account for the emergence of life histories that contribute to and thicken
whatever coherence one has in one's sense of self. In addressing this question,
you will see that our allegiance to Nietzsche in this context is not limited to his
negative insight. We also adhere to his claim that "consciousness has developed
only under the pressure of the need for communication" (1974, 298).
In order to develop Nietzsche's insight, we will make use of Habermas's
reading of Mead (Habermas 1987; 1992).' Let's return to the personalization of
social roles. Operative in communicative action (i.e., action oriented toward
mutual understanding) is another pressure individuating social roles. Individu-
als perform speech acts like expressions, questions, and promises. I cannot prom-
ise for you, you cannot accept an apology for me, and neither of us can express
the other's intentions.' Communicative competence requires, therefore, that we
present ourselves to others as individuals, both as speakers and as addressees.
But let's explore the matter further.
A source of social integration, communication enables us to coordinate
actions. If it is to do so, one needs to know what another is going to do, and as an
individual, not as a generic brother, professor, or customer. Learning to commu-
nicate involves, therefore, learning to meet an expectation performatively in-
trinsic to communication, to speak for oneself as a singular being. One finds a
similar expectation in the related practice of communicating needs. The expres-
sion of needs requires speech acts in the first person. If I am to receive what I
want or you are to provide me with what I need, I must make my needs plain to
you. These, no doubt, will be bound to social roles, that is, my needs will arise
vis-a-vis various roles that I play, e.g., teacher or friend, but unless I can express
myself in the first person, they will only be ineffectively met.
Not only expressive speech acts require the first person, however. All
speech acts do. Even when one refers to impersonal events, such as how many
miles lie between Eugene, Oregon and Ghent, Belgium, one is still expected to
provide reasons for one's beliefs should others find them puzzling, and the same
holds for conduct. In communicative action, we are expected to answer for what
we say, do, and believe, and strictly speaking, others cannot answer for us. Should
one attempt to answer for us, we will still be asked, "Is that what you meant?"
We have dipped into Habermas's theory of communicative action because
it shows how, in acquiring communicative competencies, we acquire not only
linguistic capacities but modes of self and other relation that encourage and
even require us to adopt a first person perspective. Integrating his view with
BEING INTERRUPTED 9

ours, the claim is that the "I" of first person speech becomes a structural element
in all self-positions, one dialogically tethered to actual and possible interlocu-
tors and grounded in the habits required for communicative competence. In other
words, the "I" of first-person speech is also a transactional, dialogical phenom-
enon. It is a source neither of agency nor of spontaneous judgment-those are
tied to the habits that collect around and constitute other self-positions. Instead,
it is an acquired capacity for self-regard that amounts to an internalized sense of
another's regard for one, a regard that less interjects into one a content-rich
identity than expects one to answer for what one says and does.'
On Habermas's view, and here we follow him, our communicative capac-
ity for self-regard lies at the root of life histories. Moreover, and here we are
extending his work into current discussions of the dialogical self, we contend
that it is the communicative capacity for self-regard that enables the emergence
of metapositions and the sense of self that they facilitate. The claim is that com-
municative competence makes self-knowledge possible, the kind that later forms
the basis of life histories. Communicative competence entails learning how to
answer for one's beliefs and actions. It thus demands a self-interrogation whose
fruits can be shared with and scrutinized by others, i.e., expressed linguistically.
Nietzsche succinctly summarizes the point: "The human being inventing signs
is at the same time the human being who becomes ever more keenly conscious
of himself. It was only as a social animal that man [sic] acquired self-conscious-
ness-which he is still in the process of doing, more and more" (Nietzsche 1974,
299). Note that Nietzsche's point is not that self-representations construct the
self through a quasi-transcendental constitution, but that under the pressure to
communicate, human beings have come to performatively orient themselves
toward themselves such that self-exploration and linguistic self-presentation have
become possible.
By integrating Habermas's theory of communicative action with a dia-
logical theory of the self, we are able to see how life histories are thoroughly
dialogical and not the product of a central, authorial ego. First, their subject
matter concerns the various self-positions and metapositions within which our
life unfolds, e.g., child, student, mechanic, etc. As a narrative, a life history thus
involves a dialogue among these positions. Second, life histories are not gener-
ated by some amorphous "I." Rather, and this repeats an earlier point, to say "I"
in the context of a life history is simply to take responsibility for previous and
prospective actions and beliefs. Habermas writes: "Standing within an
intersubjectively shared lifeworld horizon, the individual projects himself as
someone who vouches for the more or less clearly established continuity of a
more or less self-consciously appropriated life history" (Habermas 1992, 168).
As far as the actual telling is concerned, one will have to look again at determi-
nate self-positions and the social locations they involve. For example, one might
gather the events of one's life in therapy, or while applying for a job, or as one
ages and faces a crisis of meaning. Finally, the positions from which life histo-
10 JOHN LYSAKER AND PAUL LYSAKER

ries are gathered can themselves enter into dialogue with other self-positions.
Thus self-as-memoirist may come into contact with self-as-truthful, or self-in-
therapy may come into contact with self-as-self-sufficient. Or a life history may
produce its own metapositions, e.g., self-as-victim that comes to function
proactively alongside other self-positions. Life histories and the coherence they
bring about are thus dialogical at the level of their formal preconditions and at
the level of content. Not only do they involve a synthesis of positions, but one
pursues them from dialogically situated positions as well and on the basis of a
dialogically generated capacity.
You have before you, then, a sketch of what is involved in regarding the
self as a dialogical phenomenon. As a complex entity, a "multiplicity of souls,"
to use Nietzsche's language, the self is composed of at least two kinds of self-
positions: first-order self-positions often involving social roles, e.g., self-as-au-
thor; and metapositions that refer to and comment upon first-order self-positions,
e.g., self-as-diamond-in-the-rough. Though categorically distinct, first-order
positions can come to function in metapositional ways, e.g., self-as-criminal;
and metapositions can function as first-order positions when they come to oper-
ate prereflectively in our worldly engagements.
Within a self, self-positions are interanimating, to use Bakhtin's term,
meaning the life of a self is a life of movement and interaction among self-
positions. One kind of movement occurs in life histories where relations be-
tween first-order positions are examined and synthesized, often through the
generation of multistable metapositions like self-as-success. Such histories are
thoroughly dialogical as well, in terms of the capacities that enable them-aris-
ing, as they do, out of our acquisition of communicative competence-the sub-
ject matter that concerns them, and the self-positions from which they are
generated.
Following Dewey, we regard the life and movement of self-positions in
general as a matter of habit. We thus do not regard them as principally represen-
tational phenomena. Instead, they are intertwined and partly constitute the exis-
tential praxis that forms the bases of our being-in-the-world. Moreover, we do
not find at the source of their movements-which includes the human actions
they inform-any authorial subject, either in the form of a perpetually spectat-
ing ego or a spontaneous source of agency.
With this conception of the self as an ongoing event of dialogical ex-
changes and syntheses in mind, let us turn now to interpreting a variety of phe-
nomena characteristic of schizophrenia. Since it was first proposed as a distinct
type of "psychiatric disorder," discussion regarding schizophrenia has expanded.
Symptoms have included odd sensory experiences and beliefs, sometimes called
positive symptoms (Schneider 1959), radically diminished desire, sometimes
called negative symptoms (Carpenter et al. 1988; Kraeplin 1974), tenuous con-
nections between thoughts (Bleuler 1950; Spitzer 1997), discreet deficits in
memory and attention (Green 1996; McGhie and Chapman 1961), autism (Bovet
BEING INTERRUPTED 11

and Parnas 1991), unmodulated anger (Freeman 1969), and social deviance (Szasz
1970). Causal explanations of these symptoms have appealed to factors such as
selective abnormalities in neurodevelopment (Andreasen et al. 1998), neuro-
logical degeneration (Fucetola et al. 2000), obstetric complications (Kendell et
al. 2000), communication deviance (Wahlberg et al. 2002), social stigma
(Markowitz 1998; Wright et al. 2000), and oppressive power relations (Rudge
and Morse 2001).
Unlike the debate concerning manifest or objective features, inquiry into
the subjective experience of schizophrenia has found a more uniform phenom-
enon. The impact of schizophrenia has been likened to scenes of destruction and
devastation. Images like the collapse of a home after the erosion of its founda-
tion or an orchestra without a conductor have been employed (Minkowski 1987).
Indeed, persons with the illness often describe themselves as having been inex-
tricably damaged. For example, as a young man with schizophrenia explained,
"I used to be extroverted, outgoing, and happy," but now he could not bear to
talk to others and had hopelessly "lost the person who I used to be." It was not
that he was a different person. Instead he had become empty, his life since the
"illness" spent lying in bed, hallucinating, and awaiting the discovery of the
"right medicine." Even persons with schizophrenia who deny that anything is
"wrong" often describe a world in which a personal cataclysm can be clearly
inferred. For example, a middle-aged man, after reporting that he was not men-
tally ill, acknowledged that he was lost nonetheless. Part of his mind, he said,
had been removed the night before by female spirits. Even within potentially
empowering delusions, one often finds the same sense of loss. As another middle-
aged man described, "Just because I'm a god doesn't mean I'm not a nothing. 7
Considered as a whole, the disruption in sense of self that accompanies
schizophrenia has been characterized in terms of enduring agony (Searles 1965;
Robbins 1993), or a sense of isolation and rejection (Bassman 2000; Lysaker
and Bell 1995) that is qualitatively distinct from existential uncertainties about
fate or role (Lysaker and Lysaker 2002; Sass 1992; Selzer and Schwartz 1994).
Persons with schizophrenia may also experience a fragmentation of self where
aspects of themselves no longer cohere or are not embedded in an intelligible
history (Eigen 1986; Frosh 1983; Holma andAaltonen 1997; Laing 1978; Lysaker
et al. 2002; Rosenfeld 1954). Moreover, these profound alterations in self-con-
ception are entwined with altered experience of the world (Holma and Aaltonen
1995). Common activities such as grocery shopping can prove either so mean-
ingful or meaningless that they are impossible to participate in (Bovet and Parnas
1993; Sass 1992). Similarly, personal agency may appear to exist wholly out-
side the self (Frith 1992; Jaynes 1976; Lysaker et al. forthcoming).
In the midst of multiple symptoms and clinical features, we thus almost
always find here the felt experience of self-destruction. Now, if self-coherence
arises in an interanimating dialogue among and between first order self-posi-
tions and metapositions, both within and outside of life histories, could a dis-
12 JOHN LYSAKER AND PAUL LYSAKER

ruption in the flow of dialogue compromise a person's sense of self? Could

disruptions in internal conversation affect self-experience in a manner that par-
allels the reports and observations detailed above regarding schizophrenia? In a
previous paper (Lysaker and Lysaker 2002) we have suggested as much.
First, dialogue could cease if self-positions of either sort were no longer
ordered in a way that enabled one to respond adequately to experience. For
example, positions such as self-as-brother, self-as-unlovable, self-as-in love-
with-Karen, and so forth, might serially emerge in a context where none are
particularly called for; for example, while waiting to pay for groceries. In other
words, if something happened so that individual voices were no longer ordered
by a patterns of shifting dominance of self positions, the structure of dialogue
could disintegrate, possibly making it appear that "the conductor," or source of
agency, had disappeared. It could also seem that everything had fallen into the
metaphorical equivalent of a heap of rubble. Multiple self-positions would re-
main but without organized interaction.
A second way in which internal dialogue could be disrupted involves an
inverse process. Instead of disorganization, what if a few self-positions, or even
a solitary position, gained dominance? If singular self-positions ordered all con-
versation within and without, the self would only circulate among a limited
range of monologues. Then, what was formerly a rich array of self-positions
would be tyrannically denied entry into the conversation. In this instance, sense
of self would be sustained by a lone voice (e.g., "I am persecuted" or "I am all-
powerful"), as opposed to the cacophony described above. The myopia of such
a monologue would relentlessly tax any sense of self. In a monologue of perse-
cution, for example, former friends would become foes, and any interaction that
formerly evoked positive or loving traits would be annulled by the suspicion of
ulterior motives. Likewise, previously entertaining events that supported as-
pects of self related to casual interests, such as going to a see a movie, would be
transformed into waves of insidious assault. For persons in such a state, it is not
difficult to see how, if they recalled their earlier life, they might conclude that
parts of themselves had been lost or destroyed.
What, though, of the symptoms characteristic of schizophrenia? On our
view, the disruptions in dialogical capacity that contribute to a collapse of self
may fuel or be fueled by the major symptom clusters in schizophrenia. We are
not claiming that dialogical impairment "causes" schizophrenia. We are sug-
gesting, however, that positive and negative symptoms amplify and are ampli-
fied by difficulties in sustaining dialogue within the self and with others. In
other words, dialogical disruptions are a pathway by which self-disturbances
and symptoms influence one another.'
The first class of symptom possibly linked to dialogical disturbance in-
volves positive symptoms, including delusions (unfounded and implausible be-
liefs) and hallucinations (sensory phenomena experienced as having a
mind-independent existence that others deny). Examples of hallucinations in-
BEING INTERRUPTED 13

dude hearing and seeing persons no one else does, while examples of delusions
include convictions that one is the subject of a worldwide conspiracy, is dead,
and/or has supernatural abilities (American Psychological Association 1994).
Given our interest in dialogue we will focus upon two positive symptoms: a)
complex verbal hallucinations or hearing "voices" that command or make com-
plex utterances to or about the individual; and b) systematized delusions whose
beliefs explain a wide range of phenomenon .9
To date, systematic surveys suggest that complex hallucinations are com-
mon in acute (Benjamin 1989) and post-acute (Nayani and David 1996) phases
of schizophrenia. Complex auditory hallucinations frequently express the inten-
tion to regulate the hearer's behavior and seem omnipotent (Birchwood et al.
2000; Chadwick and Birchwood 1994; Davies et al. 1999; Leudar and Thomas
2000). Beyond causing specific behaviors, hallucination, according to Gilbert
et al. (2001), may trigger innate fight/flight defenses within the hearer. Of par-
ticular interest to us are two related points about content and the relationship of
the person to the hallucination. First, complex hallucinations tend to communi-
cate focused, singular messages. One might hear, for instance, that one is to die,
that one should flee, or that one is God. Second, the hallucination does not in-
vite the hearer into dialogue. As described by Bakhtin (1981), in a dialogical
relationship, different voices "interanimate each other" or bring significance
and complexity to one another through their interaction. In a hallucination, hearers
may fear, loath, love, or hate the voice in question, and they may debate with
themselves or others the meaning of the voice's message (e.g., Benjamin 1989;
Davies et al. 1999; Leudar and Thomas 2000). They also may shout at or dis-
tract themselves from the voice, but the voice is generally not construed as some-
thing they can influence or can talk with.
Consider, for example, a man who explained he was no longer whole
since portions of his brain had been stolen by female voices. He often heard the
spirits talk about or to him and felt that they had done something to him. Yet
they were fundamentally not a presence that could be touched or influenced by
his words. They were omnipotent. It was meaningless for him to comment on
their remarks, debate them, or give them an order. On the whole, then, halluci-
nations are experienced as a unidirectional source from which singular mes-
sages flow, urging a person to act and/or feel in a certain way.
Whether these voices have their root in abnormal spontaneous cortical
activity in the centers that support language (David 1994) or any other source,
we would suggest that their impact on the dialogical self is clear. Barraged by
authoritative commands, internal conversation is imperiled. First, given con-
stant interruptions, it suffers just as many find it hard to think and function in the
presence of loud, banging noises. Second, just as one's deliberations appear
futile in the face of an overwhelming authority, so one besieged by hallucina-
tions wielding omnipotence would be silenced and absorbed into what he or she
was commanded to do and be. Our suggestion, then, is that as hallucinatory
14 JOHN LYSAKER AND PAUL LYSAKER

voices gain strength, one's usual dialogical movements are interrupted and colo-
nized by the monologue delivered by the hallucination. As the man who experi-
enced female voices taking parts of his brain away explained, he said he was a
computer, and the voices, the programmers. From the complementary perspec-
tive of his therapist, it seemed that the voices provided a monologue that was
beyond question and that subsumed his identity. 10
Turning to systematized delusions, we similarly suggest that they may
compromise dialogical capacity. As noted, systematized delusions are stable ways
of explaining and linking together a wide range of potentially unrelated events.
Like complex verbal hallucinations, they incline a person to view the world in a
singular manner and are not regarded as matters for dialogue or reflection. In-
stead, systematic delusions form an unassailable starting point around which
one revolves, and not vice versa. Because of their impregnability, we suspect
that systematized delusions strain one's ability to sustain diverse internal con-
versations and impel one toward a state in which the self-positions associated
with the delusions are increasingly embraced at the expense of other self-posi-
tions or dialogue among positions. Consider, for example, a man who believed
himself the subject of a global conspiracy. As he explained, the presence of his
persecutors left him with only two emotions, "rage and panic," that overrode
whatever self-position might emerge or be solicited in a social exchange. Con-
sistent with this, conversations with him in psychotherapy were quite one-sided
or monological. Whenever discussing personal matters he presented himself in
terms of a self-as-angry/fearful that was a victim of omnipotent forces. Ques-
tions about his history or personal complexities were "totally irrelevant" in his
eyes, as were questions about the history or complexities of the omnipotent.
Interestingly, this man loved anthropology and could talk about it knowledga-
bly and without idiosyncrasy as long as it did not involve him personally. Thus,
when not considering himself, he seemed able to negotiate multiple self-posi-
tions (e.g., self-as-poetry-lover, self-as-interlocutor, etc.), but whenever a self-
relation was drawn out in conversation, this fluid movement among self-positions
was swept up into a monological stream of persecution.
Thus far we have attempted to illustrate how the presence of verbal hallu-
cinations and systematized delusions generally hinder the richness and diversity
of internal dialogue. Before we turn to another symptom, we also wish to sug-
gest that the relationship of positive symptoms to dialogue may be circular,
developing momentum as distinct self-positions are absorbed. Just as positive
symptoms imperil dialogue, disruptions in internal dialogue may heighten posi-
tive symptoms. Our hypothesis is that with fewer self-positions available the
singular impelling voice of the hallucination or delusion may gain strength. Put
another way, if one has few voices within oneself, it might prove increasingly
difficult not to follow and be defined by one's symptoms. For example, with a
loss of self-positions (e.g., student, son, friend), there would seem to be fewer
and fewer resources from which to draw the strength to reject a delusion or
hallucinated command. With fewer previous self-positions available it would
BEING INTERRUPTED 15

seem necessarily more difficult to reject delusions or hallucinations by saying

"That is not me," or "That is not the kind of person I am."
At the phenomenological level, then, we find two processes that could
feed off of one another. Decrements in dialogical capacity and thereby in sense
of self may heighten vulnerability to positive symptoms. Second, positive symp-
toms could infect self-positions and corrode the social relations each entails,
turning teachers, parents, and lovers into one more persecuting force, leaving
the self with only the voice of a victim. As a possible illustration of this we turn
again to the man whose mind was being stolen by female voices. As psycho-
therapy progressed, he expressed more and more complex self-positions. He
retained the voice of someone humiliated and injured but also allowed to sur-
face, in a more reflective, nuanced manner, the voice of someone thirsting for
revenge, who enjoyed antisocial practices, and was also deeply ashamed. To us
this suggests that with greater dialogical capacity he could resist certain positive
symptoms and with fewer positive symptoms his dialogical capacity could
deepen.
While positive symptoms entail the presence of something unexpected,
negative symptoms suggest the absence of something, such as emotion, social
interest, or desire. (APA 1994). The prevailing view is that negative symptoms
have unique etiological roots and are functionally independent of positive symp-
toms (Andreasen et al. 1990). For our purposes we wish to consider two specific
negative symptoms: flat affect, or a lack of emotional expression; and distur-
bance of volition, the absence of any meaningful sense of direction in life. A
person who might be described as having blunted affect would show a limited
range of emotion, perhaps appearing wooden or lifeless in the midst of a cel-
ebration or time of sadness. In contrast to a depressed person who might silently
be consumed by pain, someone with flat affect would feel emptiness. In paral-
lel, someone experiencing a disturbance of volition would be unable to initiate
goal-directed activity or make purposeful decisions about his life course. As
one man explained, the source of his disability was not his positive symptoms.
Instead, not having a direction in life was crippling him (Lysaker and Bell 1995).
As with positive symptoms, we suggest that these negative symptoms
could disrupt internal dialogue and be affected by disruptions in dialogue. If one
experiences a decrease in affect, might the strength of certain self-positions erode,
disrupting the capacity to play various social roles? Recall the different facets of
Crime and Punishment's main character: "sullen, gloomy, arrogant, proud ...
insecure ...magnanimous and kind ... cold and callous ... always in a hurry,
always too busy and lies there doing nothing." What if the affects that bound
together the proud, insecure, callous, and gloomy self-positions were signifi-
cantly weakened? Without enough animating affect, how could one be proud,
insecure, or gloomy? Moreover, without affect, what would compel one to ful-
fill the expectations that help define social roles? Our suggestion is that bereft
of affect, a self-position falls out of any hierarchy and virtually disappears from
internal dialogue, just as one's self-position as political actor falls out of inter-
16 JOHN LYSAKER AND PAUL LYSAKER

nal dialogue if one is politically apathetic. This is not to say that there is a sim-
plistic, linear relationship between affect and dialogue. But if dialogue is an
interanimating process, without enough animating force of affect, it might largely
halt.
Self-positions are not only animated by the presence of affect, however,
but also by their participation in the larger narratives that give meaning to par-
ticular struggles and events. For example, being a student is animated in part by
working toward a degree that will edify and improve employment opportuni-
ties. But what if the sense of life direction that binds together and solicits self-
positions integral to being a student fell to the way side (e.g., self-as-hard-working
and self-as-communicative)? It strikes us that such a person would no longer
experience themselves as a hard worker, for they would have nothing to work
toward. Our second suggestion, then, is that bereft of orienting purposes, self-
positions lack animation and thus lie dormant.
As with positive symptoms, we also think that the interaction of negative
symptoms of dialogical capacity is bidirectional or circular. If one is unable to
draw together the various self-positions that are integral to being a student (e.g.,
classmate and hard worker) the project itself (e.g., contributing to group projects
and tracking down sources) would prove disjointed and incoherent. Likewise,
the desirability of the end, here graduating, would wane if the means were no
longer available. Consider the hypothetical person who has lost the ability to
sustain conversation internally. Our suggestion is that in the wake of a loss of
dialogical capacity, the individual could be swept into a position where, to re-
duce confusion and a feeling of failure, dedication to various projects and feel-
ing for particular opportunities and events would lessen, thus contributing to a
cycle of decline.
Note that we are not claiming that with loss of affect or direction in life
all inner conversation stops. Rather, our claim is that the self-positions that be-
long to life projects and about which one is enthused or anxious would remain
mostly dormant, leaving one with basic self-positions, associated with meeting
subsistence needs, whose emergence remains relatively isolated. Devoid of
multiple and interacting self-positions, such a self would have little to talk about
and little would unfold in the course of a life story. In such a state a person might
turn the ownership of their self-conception over to others or limit that under-
standing to a superficial account or "press release," that is, one devoid of the
comparisons and syntheses that evolve into metapositions and give us a sense of
continuity over time. And with little sense of who one might be over time, devo-
tion to complex, long-range projects would wane.
As an illustration, consider another man with schizophrenia who, when
asked for his side of his life's story, found the question absurd. He thought it
was "funny" that it was a "doctor" asking, because only a doctor could under-
stand the contours of his life. When challenged, he could describe being angry
with his wife for not letting him drive to the grocery store, but beyond that,
elements of his dialogues were terse and unconnected, and did not extend into
BEING INTERRUPTED 19

Birchwood, M., A. Meaden, P. Trower, P. Gilbert, and J. Plaistow. 2000. "The Power and Omnipo-
tence of Voices: Subordination and Entrapment by Voices and Significant Others." Psycho-
logical Medicine 30: 337-34.
Borges, J. L. 1962. Labyrinths: Selected Stories and Other Writings. New York: New Directions
Press.
Bovet, P., and J. Parnas. 1991. "Autism in Schizophrenia Revisited." Comprehensive Psychiatry
32: 7-21.
. 1993. "Schizophrenia Delusions: A Phenomenological Approach." Schizophrenia Bulle-
tin 19: 579-97.
Calasso, R. 1994. The Marriage of Cadmus and Harmony. Trans. T. Parks. New York: Vintage
International.
Carpenter, W. T., D. W. Heinrichs, and A. M. Wagman. 1988. "Deficit and Nondeficit Forms of
Schizophrenia." American Journal of Psychiatry 145: 578-83.
Carroll, A., S. Fattah, Z. Clyde, I. Coffey, D. G. C. Owens, and E. C. Johnstone. 1999. "Correlates
of Insight and Insight Change in Schizophrenia." Schizophrenia Research 35: 247-53.
Chadwick, P., and M. Birchwood. 1994. "The Omnipotence of Voices: A Cognitive Approach to
Auditory Hallucinations." British Journal of Psychiatry 164: 190-201.
Davey, N. 1987. "Nietzsche and Hume on Self and Identity." Journal of the British Society of
Phenomenology 18: 14-29.
David, A. S. 1994. "The Neuropsychological Origin of Auditory Hallucinations." In The Neurop-
sychiatry ofSchizophrenia, ed. A S. David and J. C. Cutting. Mahwah, NJ: Lawrence Erlbaum.
Davidson, L., and J. Strauss. 1992. "Sense of Self in Recovery from Mental Illness." British Jour-
nal ofMedical Psychology 65: 131-45.
Davies, P., P. Thomas, and I. Leudar. 1999. "Dialogical Engagement with Voices: A Single Case
Study." British Journal of Medical Psychology 27: 179-87.
Dewey, John. 1988 [1922]. The Middle Works of John Dewey. Vol. 14, Human Nature and Con-
duct. Carbondale: Southern Illinois University Press.
Dostoyevsky, Fyodor. 1993 [1866]. Crime and Punishment. New York: Alfred A. Knopf.
Duckworth, K., V. Nair, J. K. Patel, and S. Goldfinger. 1997. "Lost Time, Found Hope and Sorrow,
the Search for Self, Connection and Purpose During Awakenings on the New Antipsychotics."
Harvard Review of Psychiatry 5: 227-33.
Eigen, M. 1986. The Psychotic Core. New York: Jason Aronson.
Frankel, B. 1993. "Groups for the Chronic Mental Patient and the Legacy of Failure." Interna-
tional Journal of Group Psychotherapy 43: 157-72.
Freeman, T. 1969. The Psychopathology of the Psychoses. New York: International Universities
Press.
Frese, F. J. 1993. "Twelve Aspects of Coping for Persons with Schizophrenia." Innovations and
Research 2: 39-46.
Frith, C. D. 1992. The Cognitive Neuropsychology of Schizophrenia. Hove: Lawrence Erlbaum.
Frosh, J. 1983. The Psychotic Process. New York: International Universities Press.
Fucetola, R., et al. 2000. "Age and Neurologic Function in Schizophrenia: A Decline in Executive
Abilities Beyond That Observed in Healthy Volunteers." Biological Psychiatry 48: 137-46.
Gilbert, P., M. Birchwood, J. Gilbert, P. Trower, J. Hay, B. Murray, A. Meaden, K. Olsen, and J. N.
V. Miles. 2001. "An Exploration of Evolved Mental Mechanisms for Dominant and Subordi-
nate Behavior in Relation to Auditory Hallucinations in Schizophrenia and Critical Thoughts
in Depression." British Journal of Medical Psychology 31: 1117-27.
Green, M. F. 1996. "What Are the Functional Consequences of Neurocognitive Deficits in Schizo-
phrenia?" American Journal of Psychiatry 1533: 321-30.
Gregg, G. S.1995. "Multiple Identities and the Integration of Personality." Journal of Personality
63: 617-41.
Habermas, Jiirgen. 1987 [1981]. Theory of Communicative Action. Vol. 2. Boston: Beacon Press.
. 1992 [1988]. Postmetaphysical Thinking. Cambridge, MA: MIT University Press.
20 JOHN LYSAKER AND PAUL LYSAKER

Harding, C. M., J. Zubin, and J. Strauss. 1992. "Chronicity in Schizophrenia." British Journal of
Psychiatry 161 (supp. 18): 27-37.
Hermans, H. J. M. 1996a. "Opposites in a Dialogical Self: Constructs as Characters." Journal of
Constructive Psychology 9: 1-26.
. 1996b. "Voicing the Self: From Information Processing to Dialogical Interchange." Psy-
chological Bulletin 119: 31-50.
. 2002. "The Dialogical Self as a Society of Mind." Theory and Psychology 12: 147-61.
Hermans, H. J. M., T. I. Rijks, and H. J. G. Kempen. 1993. "Imaginal Dialogues in the Self:
Theory and Method." Journal of Personality 61: 207-36.
Holma, J., and J. Aaltonen. 1995. "The Self-Narrative and Acute Psychosis." Contemporary Fam-
ily Therapy 17: 307-16.
.1997. "The Sense of Agency and the Search for Narrative in Acute Psychosis." Contempo-
rary Family Therapy 19: 463-77.
Hume, David. 1888 [1734]. A Treatise of Human Nature. Oxford: Oxford University Press.
Jaynes, J. 1976. The Origins of Consciousness in the Breakdown of the Bicameral Mind. Boston:
Houghton Mifflin.
Karon, B. P., and G. R. Van Denbos. 1981. Psychotherapy of Schizophrenia: The Treatment of
Choice. New York: Jason Aronson.
Kendell, R. E., K. Mclnneny, E. Juszcak, and M. Bain. 2000. "Obstetric Complications and Schizo-
phrenia: Two Case Control Studies Based on Structured Obstetric Records." British Journal of
Psychiatry 176: 516-26.
Kierkegaard, S. 1980 [1849]. The Sickness unto Death. Princeton: Princeton University Press.
. 1992 [1846]. The Concluding Unscientific Postscripts. Princeton: Princeton University
Press.
Kline, J., D. Horn, and C. M. Patterson. 1996. "Meaning and Development in the Interpersonal
Treatment of Severe Psychopathology." Bulletin of the Menninger Clinic 60: 314-15.
Kraeplin, E. 1974 [1911]. Lecture on Clinical Psychiatry. Trans. Thomas Johnson. New York:
Hairier.
Laing, R. D. 1978. The Divided Self. New York: Penguin Books.
Leudar, I., and P. Thomas. 2000. Voices of Reason, Voices of Insanity: Studies of Verbal Hallucina-
tions. London: Routledge.
Lysaker, J. T. 1996. "The Shape of Selves to Come: Rorty and Self Creation." Philosophical and
Social Criticism 22: 39-74.
Lysaker, P. H., and M. D. Bell. 1995. "Work and Meaning: Disturbance of Volition and Vocational
Dysfunction in Schizophrenia." Psychiatry 58.4: 392-400.
Lysaker, P. H., M. D. Bell, G. J. Bryson, and E. Kaplan. 1998. "Psychosocial Function and Insight
in Schizophrenia." Journal of Nervous and Mental Disease 186: 432-36.
Lysaker, P. H., C. A. Clements, C. Placak Hallberg, S. J. Knipschure, and D. E. Wright. 2002.
"Insight and Personal Narratives of Illness in Schizophrenia." Psychiatry 65: 197-206.
Lysaker, P. H., and C. F. France. 1999. "Psychotherapy as an Element in Supported Employment
for Persons with Severe Mental Illness." Psychiatry 62: 209-22.
Lysaker, P. H., and J. T. Lysaker. 2001a. "Psychosis and the Disintegration of Dialogical Self-
Structure: Problems Posed by Schizophrenia for the Maintenance of Dialogue." British Jour-
nal of Medical Psychology 74: 23-33.
. 2001b. "Schizophrenia and the Collapse of the Dialogical Self: Recovery, Narrative, and
Psychotherapy." Psychotherapy 38: 252-61.
. 2002. "Narrative Structure in Psychosis: Schizophrenia and Disruptions in the Dialogical
Self." Theory and Psychology 12: 207-20.
Lysaker, P. H.,A. M. Wickett, N. Wilke, and J. T. Lysaker. Forthcoming. "Narrative Incoherence in
Schizophrenia: The Absent Protagonist, Neurocognitive Impairments, and Fear of Audience."
American Journal of Psychotherapy.
Mandelstam, O. 1979 [1919]. The Complete Critical Prose and Letters. Ann Arbor: Ardis.
BEING INTERRUPTED 21

Markowitz, F. E. 1998. "The Effects of Stigma on the Psychological Well-Being and Life Satisfac-
tion of Persons with Mental Illness." Journal of Health and Social Behavior 39: 335-47.
McGhie, A., and J. Chapman. 1961. "Disorders of Attention and Perception in Early Schizophre-
nia." British Journal ofMedical Psychology 34: 103-15.
Mead, G. H. 1967 [1934]. Mind, Self, and Society. Chicago: University of Chicago Press.
Minkowski, E. 1987. "The Essential Disorder Underlying Schizophrenia and Schizophrenic
Thought." In The Clinical Roots of the Schizophrenic Concept, ed. J. Cutting and M. Shep-
herd, 188-212. Cambridge: Cambridge University Press.
Nayani, T. H., and A. S. David. 1996. "The Auditory Hallucination: A Phenomenological Survey."
Psychological Medicine 26: 177-89.
Nietzsche, F. 1966 [1886]. Beyond Good and Evil. New York: Random House.
. 1974 [1882]. The Gay Science. New York: Random House.
Porte, J., and S. Morris, eds. 2001. Emerson's Prose and Poetry. New York: W. W. Norton.
Robbins, M. 1993 Experiences of Schizophrenia. New York: Guilford Press.
Roe, D., and A. B. Ben-Yaskai. 1999. "Exploring the Relationship Between the Person and the
Disorder Among Individuals Hospitalized for Psychosis." Psychiatry 62: 372-80.
Rosenfeld, H. 1954. "Considerations Regarding the Psychoanalytic Approach to Acute and Chronic
Schizophrenia." International Journal of Psychoanalysis 39: 274-75.
Rudge, T., and K. Morse. 2001. "Re-awakening?: A Discourse Analysis of the Recovery from
Schizophrenia after Medication Change." Australian and New Zealand Journal ofMental Health
Nursing 10: 66-76.
Sass, L. A. 1992. "Heidegger, Schizophrenia, and the Ontological Difference." Philosophical Psy-
chology 5: 109-33.
Schneider, K. 1959 Clinical Psychopathology. New York: Grune & Stratton.
Schwartz, R. C. 1998. "The Relationship between Insight, Illness, and Treatment Outcome in
Schizophrenia." Psychiatric Quarterly 69: 1-22.
Searles, H. 1965. Collected Papers of Schizophrenia and Related Subjects. New York: Interna-
tional Universities Press.
Selzer, M. A., and F. Schwartz. 1994. "The Continuity of Personality in Schizophrenia." Journal
of Psychotherapy Practice and Research 3: 313-24.
Spitzer, M. 1997. "A Cognitive Neuroscience View of Schizophrenic Thought Disorder." Schizo-
phrenia Bulletin 23: 29-50
Startup, M. E. 1996. "Insight and Cognitive Deficits in Schizophrenia: Evidence for a Curvilinear
Relationship." Psychological Medicine 26: 1277-81.
Szasz, T. S. 1970. The Manufacture ofMadness. New York: Harper & Row.
Vygotsky, L. S. 1978. Mind in Society. Cambridge, MA: Harvard University Press.
Wahlberg, K. E., L. C. Wynne, H. Oja, P. Keskitalo, H. Anais-Tanner, P. Koistinen, T. Tarvainen,
H. Hakko, J. Moring, M. Naarala, A. Sorri, and P. Tienari. 2002. "Thought Disorder Index of
Finnish Adoptees and Communication Deviance of Their Adoptive Parents." Psychological
Medicine 30: 127-36.
Warner, R., D. Taylor, M. Powers, and R. Hyman. 1989. "Acceptance of the Mental Illness Label by
Psychotic Patients: Effects on Functioning." American Journal of Orthopsychiatry 59: 389-409.
Wexler, M. 1971. "Schizophrenia as Conflict and Deficiency." Psychoanalytic Quarterly 40: 83-100.
Whicher, Stephen, et al., eds. 1964 [1836]. The Early Lectures of Ralph Waldo Emerson. Vol. 2,
1836-1838. Cambridge, MA: Harvard University Press.
Wright, E. R., W. P. Gronfein, and T. J. Owens. 2000. "Deinstitutionalization, Social Rejection,
and the Self Esteem of Former Mental Patients." Journal of Health and Social Behavior 41:
68-90.
Young, S. L., and D. S. Ensign. 1999. "Exploring Recovery from the Perspective of Persons with
Psychiatric Disabilities." Psychosocial Rehabilitation Journal 22: 219-31.