Abstract
Here I shall consider an assumption that is widespread in psychoanalysis, psychiatry, and clinical psychology, and that is presented with characteristic subtlety in the writings of David Shapiro. This is the notion that the essential touchstone or yardstick of mental health is a person’s capacity for what Shapiro alternatively terms “autonomy,” “agency,” “intentionality,” or “self-directed action.” Corollary ideas are (1) that degrees of psychopathology correlate with a person’s or patient’s distance from this ideal, and (2) that the essential purpose of psychotherapy will be to increase one’s sphere of self-awareness and personal agency. Shapiro’s presentation of this extremely influential notion or assumption is the richest and clearest of which I am aware in clinical psychology or psychiatry. I will criticize the adequacy of this notion in relation to what is perhaps the most severe form of psychopathology: the schizophrenic disorders, a topic Shapiro mentions in Autonomy and Rigid Character (AR, published in 1981) and treats at length in Dynamics of Character (DC 2000). Part of my discussion focuses on the nature of schizophrenic symptoms in particular. The other part concerns the ambiguity of the psychological concepts in question – namely, personal “autonomy” as well as closely related notions including agency, volition, self-direction, and free will.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsNotes
- 1.
Shapiro writes that all psychopathology “will involve some loss of autonomy … probably the more severe the pathology, the greater the loss” (AR p. 31). He describes the “essential aim of psychotherapy” as to introduce the patient to his own “authorship of his own actions… and to enlarge his experience of it” (p. 10). See also Dynamics of Character, pp. 19 and 127, where Shapiro cites Roy Schafer and Helmuth Kaiser.
- 2.
Shapiro speaks of “a loss or weakening of the experience of self-direction (synonymous in my use with agency) and a corresponding attenuation of the actual processes of volitional action” (DC p. 126).
- 3.
Shapiro asks whether “the loss of volitional direction of thought and attention” is “the primary deficiency in schizophrenia from which its other symptoms derive; and, if the latter, whether it can be understood as a defensive reaction or, on the contrary, is a directly biological deficiency” (DC p. 134). “Thus we are led to the possibility that the impairment of volitional direction in schizophrenia may also constitute an anxiety-forestalling reversion – in this case a radical one – to prevolitional modes” (DC p. 127f). He describes his hypothesis as follows: “that the symptoms of schizophrenia, though not themselves defensively purposeful, are products of a radical surrender of volitional direction of thought that is defensive in origin” (DC p. 135).
- 4.
I consider myself something of a disciple of Shapiro’s. I was fortunate to have been assigned Neurotic Styles in one of the first psychology courses I took as an undergraduate, and Shapiro’s perspective has profoundly influenced my thinking ever since. Together with Laing’s Divided Self and Merleau-Ponty’s Phenomenology of Perception, Shapiro’s book inspired me to study clinical psychology.
- 5.
Some related issues are discussed in Sass (2007).
- 6.
Neurotic Styles begins as follows: “This book had its beginnings in the noticing of certain facts about various pathological conditions and certain specific clinical conclusions—long before I would have considered these to represent a ‘point of view.’ … if I take some pains in this introduction to explain its orientation, it is not with an interest in theoretical argument, but to guide the reader in his understanding of the clinical chapters that follow” (p. 1) Some pages later in his Introduction: “I will have little to say about the possible origins of the neurotic styles to be discussed here … Careful study of the styles themselves and a clearer, more detailed picture of the forms of cognition, activity, emotional experience, and so on, that characterize various pathological conditions is, I am convinced, an indispensable prerequisite to an understanding of origins” (p. 15).
- 7.
In my view, this would better be described as a widely held claim (in psychoanalysis), rather than an item of “knowledge.” Shapiro writes that in one respect (absence of “clear, objective picture” of the world), “the rigidity of adult psychopathology is not different from the child’s” (DC p. 76), even though one is due to incapacity and the other to defensive dynamics. But if one is concerned with assessing forms or degree of autonomy, the latter would seem to be a crucial difference—as I will show.
- 8.
This is Donald Davidson’s definition: a movement is an action if it is caused, in a specific way, by the combination of a desire and a belief.
- 9.
The phrase comes from Susan Wolf (1993), who identifies Frankfurt and others inspired by his approach as offering “theories of the true self.”
- 10.
For discussion of this aspect, see Laing (1965); also Sass (1992,Chapter 3). Hannah Arendt makes a useful distinction between what she calls “labor,” “work,” and “action.” In the first, animal desire for bare existence is served. In the second, there is elaborate control of the environment; but each individual is interchangeable, merely serving a role in the production process. Only in the third – “action” – are the intentions and personal character of the agent made manifest. Persons in the schizophrenia spectrum sometimes seem particularly uninterested in both labor and work (witness their lack of interest in ADLs – activities of daily living – and in cooperative labor) and concerned only with “action” – the most individualized and expressive of the three modes. (I thank Jeffery Geller for alerting me to the relevance of Arendt’s distinction.)
- 11.
Three of the four other types listed by Arpaly (2004) are not necessarily more absent in schizophrenia than in normal individuals or other forms of pathology; I would not however claim that they are especially prominent in schizophrenia. These are the following: (1) normative, moral autonomy, the ability to make one’s own decisions free from intervention or false information. (2) Having a harmonious and coherent self-image, as in the case of a person who does not experience her desires as an external threat. (3) The ability to respond to reasons. The final type, “agent autonomy,” refers to the issue of self-control or self-government: the ability to decide which motivational state to follow. This has affinities with Frankfurt’s conception of autonomy, and is discussed in the course of this article.
- 12.
There is no control group in Stanghellini and Ballerini’s (2007) study. It seems obvious however that the positions espoused by their schizophrenia-spectrum patients are more extreme than one would typically find in a normal population or in other diagnostic groups.
- 13.
Objections 1 and 3 are reminiscent of some recent philosophical criticisms of Frankfurt’s view. See notes following.
- 14.
This objection recalls criticisms of Frankfurt’s position that question his privileging of second-order desires and volitions by arguing that there is, in fact, no reason to view these as necessarily capturing the person’s authentic or autonomous will. Is it not possible, for instance, that a person could be incapable of being reflective about his second-order desires? See Watson (1975); also Thalberg (1978).
- 15.
This objection recalls criticisms of Frankfurt that recommend focusing on the process through which second-order desires develop. See, e.g., Christman (1991). Christman emphasizes the agent’s acceptance or rejection of the process of formation of his desire; an alternative approach might seek other, less subjective bases of evaluation of this process.
- 16.
One might wonder, in fact, whether the schizophrenic persons apparent autonomy is somehow akin to the way in which a neurological patient with involuntary motor tics may nevertheless find ways to incorporate these tics into action sequences that only appear to be purposeful. Still another objection might involve saying that the patient’s statements of autonomy are, in some sense, “empty speech acts” devoid of meaningful or representational content (see Berrios 1991) – no more than a recycling of cultural clichés that are not really understood by the patient. Is it, perhaps, an over-extension of the famous “principle of charity” to interpret such statements as being meaningful in any straightforward sense? Both these objections seem implausible. First, the actions in question often involve highly complex behavior-sequences that require executive functioning and have little in common with tics (see section on “Action” in this paper). Also, both the coherence of the patients’ statements and the consistency of these statements with complex forms of non-automatic action, suggest that the speech acts could not be devoid of meaningful content or commitment.
- 17.
Minkowski (1927) describes a very similar case.
- 18.
Shapiro quotes from Harry Guntrip’s writing on schizoid personality. However, he ignores the dialectical element in the accounts by Guntrip and Fairbairn, both of whom recognize the presence of an underlying and intermittently emergent sensitivity/vulnerability and a capacity for acute introspective awareness, as well as an insistence on autonomy (both at the level of values and of action) that are also common in many schizoid individuals (see also Laing 1965). Shapiro’s comparison of schizoids with psychopathy seems odd, since schizoid individuals are typically dominated by forms of self-consciousness, hesitation, and psychological distancing mechanisms that have little in common with impulsive traits. See Madness and Modernism (Sass 1992, Chapter 3) for critical discussion of conceptions of schizoid personality, including both the uni-dimensional model implicit in DSM III and IV and the British object-relations approach.
- 19.
Shapiro offers this sort of analysis in his treatment of adolescence. He recognizes that adolescents are “concerned with the right, in principle, to hold their own views, to follow their own lights, to be in charge of themselves. They are explicitly and consciously aware of and concerned with the matter of autonomy or self-determination itself …” He speaks of forms of “exaggerated willfulness, defensiveness, and other symptoms of an unsteady, self-conscious, and sometimes simply artificial assertion of autonomy and personal authority” (AR 66–67), thus characterizing these acts and assertions as mere pseudo-autonomy.
- 20.
In this sense the term “mechanism” in the phrase “defense mechanisms” is somewhat misleading.
- 21.
One might wish to impose, as a criterion of autonomy, that the person remain in basic touch with consensual reality, and to argue that this is not the case with such patients. However, some such withdrawn, schizophrenic persons do show significant recognition of the merely virtual nature of their delusional or quasi-delusional worlds. Good examples are the famous patients Paul Schreber and Adolf Wölfli; discussed by Sass (1994, 1997, 2004).
- 22.
One of most plausible neuro-cognitive approaches to schizophrenia hypothesizes a disturbance of the hippocampus-based “comparator” system – the system that normally enables the cognitive-perceptual system to take familiar information for granted, i.e., to experience it in an implicit manner while directing focal attention toward that which is novel and unexpected (Hemsley 2005). One consequence of disturbance to this system would be disruption of the explicit-focus/implicit-background relationship that is essential to Blankenburg’s “natural self-evidence.” Stimuli that would normally fade into the background of awareness because of their sheer familiarity, would tend instead to become objects of focal awareness.
- 23.
In Dynamics of Character Shapiro makes it very clear that he wishes to extend the neurosis model to account for aspects of psychosis.
- 24.
See earlier note re hippocampus-based “comparator” function.
- 25.
For rich analysis of one such individual, a patient who cut his grandmother’s throat despite seeming to have no history or current feelings of hostility toward her, see Castel (2009).
- 26.
See Jouan (2009) for interesting arguments regarding the (paradoxical) need for autonomous actions to be rooted in a kind of passivity, that of a passion or basic commitment that is itself not freely chosen.
- 27.
An interesting formulation of the latter possibility can be found in Dementia Praecox or the Group of Schizophrenias, where Eugen Bleuler (1950) speculates not only that affective decline may be more fundamental than the thinking disturbance in schizophrenia, but that this decline may largely involve defensive shutting-down as protection against disorganizing affect (pp. 41–51, 65–68, 364–369). Shapiro presents evidence that seems very supportive of the fundamental, organizing role of affect- or drive-related factors. He cites Thomas Freeman’s observation re catatonic schizophrenia patients that “coherent, fluent, and logical speech appeared when they were angry or under the pressure of a need [such as hunger].” Here, as Shapiro acknowledges, the “momentary emergence of spontaneous purpose, possible under these conditions without self-consciousness, organizes thought and speech” (DC, p. 140).Shapiro also acknowledges that, in schizophrenia, we must consider “an effect in the opposite direction”: not “the weakening of the experience of external reality that follows from the restriction or loss of volition” but rather, “the effect on volitional direction of a loss of clear external objectives” (DC, pp. 144–145). Fair enough. But Shapiro goes on to insist that the “loss of a clear and stable sense of external reality [must itself be] a by-product of the defensive retreat from volitional experience” – a by-product that “may in turn assume proportions that deprive the individual of the external objects that volitional direction requires.” I hear the ring of special pleading here.
- 28.
See also Taylor’s criticism of the notion of “radical choice” (Taylor 1976).
- 29.
For an excellent study of the autonomy ideal and its possible association with psychopathology and conceptions thereof, see Ehrenberg (1998).
- 30.
In a later work, Susan Wolf describes this as the ability to act in conformity with and on the basis of the True and the Good (Wolf 2005, p. 71).
- 31.
For a similar approach, see Honneth (1993).
- 32.
At the end of her article, Wolf (1987) explicitly acknowledges the normative nature of her concept of mental health, and hence of her notion of autonomy.
- 33.
Re this point, see Chapter 10.
References
Arpaly, N. (2004). Which autonomy? In J. K. Campbell, M. O’Rourke, & D. Shier (Eds.), Freedom and determinism (pp. 173–188). Cambridge: MIT Press.
Barham, P. (1984). Schizophrenia and human value. Oxford: Blackwell.
Berrios, G. E. (1991). Delusions as “wrong beliefs”: A conceptual history. British Journal of Psychiatry 159 (Suppl. 14), 6–13.
Berze, J., & Gruhle, H. W. (1929). Psychologie der schizophrenie. Berlin: Springer.
Binswanger, L. (1956). Drei Formen missglückten Daseins. Tubingen: Max Niemeyer (quoted in Stanghellini & Ballerini 2007).
Binswanger, L. (1987). Extravagance, perverseness, manneristic behavior and schizophrenia. In J. Cutting & M. Shepherd (Eds.), The clinical roots of the schizophrenia concept (pp. 83–88). Cambridge: Cambridge University Press.
Blankenburg, W. (1971). Der Verlust der natürlichen Selbstverständniskeit. Stuttgart: Ferdinand Enke.
Blankenburg, W. (2001). First steps toward a psychopathology of ‘common sense’. Philosophy, Psychiatry & Psychology, 8, 303–315.
Bleuler, E. (1950). Dementia praecox or the group of schizophrenias (J. Zinkin, Transl.). New York: International Universities Press.
Bleuler, M. (1978). The schizophrenic disorders. New Haven/London: Yale University Press.
Castel, P.-H. (2009). Folie et responsabilité (Contrepoint philosophique à “Moi, Pierre Rivière…”). In M. Jouan & S. Laugier (Eds.), Comment penser l’autonomie ? Entre compétences et dépendances. Paris : PUF.
Christman, J. (1991). Autonomy and personal history. Canadian Journal of Philosophy, 21, 1–24.
Corin, E. (1990). Facts and meaning in psychiatry: An anthropological approach to the lifeworld of schizophrenics. Culture, Medicine, and Psychiatry, 14, 153–188..
Cutting, J. (2009). Scheler, phenomenology, and psychopathology. Philosophy, Psychiatry, Psychology, 16, 143–159.
Ehrenberg, A. (1998). La fatigue d’être soi: Dépression et societé. Paris: Odile Jacob.
Frankfurt, H. (1971). Freedom of the will and the concept of a person. Journal of Philosophy, 68, 5–21.
Gauchet, M. (2003). La condition historique. Paris: Gallimard.
Hackett, P. (1952). The cardboard giants. New York: G. P. Putnam’s Sons.
Hemsley, D.R. (2005). The development of a cognitive model of schizophrenia: Placing it in context. Neuroscience and Biobehavioral Reviews, 29, 977–988.
Heveroch, Dr. (1913). Über die Störungen des Ichtums. Zeitschrift für die gesamte Neurologie and Psychiatrie, 19: 422–496 (cited in Landis, 1964, p. 347).
Honneth, A. (2008). L’autonomie décentrée : Les conséquences de la critique moderne du sujet pour la philosophie morale. In M. Jouan (Ed.), Psychologie morale : Autonomie, responsabilité, et rationalité pratique (pp. 347–363). Paris: Vrin (original in German, 1993).
Jouan, M. (2008). Introduction générale. In M. Jouan (Ed.), Psychologie morale: Autonomie, responsabilité, et rationalité pratique (pp. 7–37). Paris : Vrin.
Jouan, M. (2009). Les limites de l’expression de soi chez Harry Frankfurt : Une lecture de La Vie des Autres. In M. Jouan and S. Laugier (Eds.), Comment penser l’autonomie ?(pp. 319–342). Paris: Presses Universitaires de France.
Jouan, M., & Laugier, S. (2009). Présentation. In M. Jouan & S. Laugier (Eds.), Comment penser l’autonomie? (pp. 1–16). Paris: Presses Universitaires de France.
Kant, I. (1965). The critique of pure reason, Unabridged Edition, translated by N. K. Smith. New York: St Martin’s (from 2nd ed., 1787).
Laing, R. D. (1965). The divided self. Harmondsworth: Penguin.
Landis, C. (1964). Varieties of psycho-pathological experience. New York: Holt, Rinehart & Winston.
Lecours, A. R., & M. Vanier-Clement,M. (1976). Schizophasia and jargonaphasia, Brain and Language, 3, 1976.
Lin, K.-M., & Kleinman, A. (1988). Psychopathology and clinical course of schizophrenia: A cross-cultural perspective. Schizophrenia Bulletin, 14, 555–567..
Menand, L. Regrets only: Lionel Trilling and his discontents, New Yorker, Dec 27 2008.
Merleau-Ponty, M. (1962). Phenomenology of perception (Transl. C. Smith). London: Routledge & Kegan Paul.
Minkowski, E. (1927). La Schizophrénie. Paris: Payot.
Møller, P., & Husby, R. (2000). The initial prodrome in schizophrenia: Searching for naturalistic core dimensions of experience and behavior. Schizophrenia Bulletin, 26, 217–232.
Pfander, A. (1911). Motive and motivation. In A. Pfander (Ed.), Münchner philophische abhandlungen (Festschrift für Theodor Lipps) (pp. 163–195). Leipzig: Barth.
Ricoeur, P. (1966). Freedom and nature: The voluntary and the involuntary (Transl. F. V. Kovak). Chicago: Northwestern University Press.
Ryan, R. M., Kuhl, J., & Deci, E. L. (1997). Nature and autonomy: An organizational view of social and neurobiological aspects of self-regulation in behavior and development. Development and Psychopathology, 9, 701–728.
Sass, L. (1992). Madness and modernism: Insanity in the light of modern art, literature, and thought. New York: Basic Books (Harvard paperback 1994).
Sass, L. (1994). The paradoxes of delusion: Wittgenstein, Schreber, and the schizophrenic mind. Ithaca/London: Cornell University Press.
Sass, L. (1997). Adolf Wölfli, spatiality, and the sublime. In E. Spoerri (Ed.), Adolf Wölfli: Draftsman, poet, composer (pp. 136–145). Ithaca/London: Cornell University Press.
Sass, L. (2001). Self and world in schizophrenia: Three classic approaches. Philosophy, Psychiatry, Psychology, 8, 251–270.
Sass, L. (2004). Affectivity in schizophrenia: A phenomenological perspective. Journal of Consciousness Studies, 11, 127–147.
Sass, L. (2007). “Person with schizophrenia” or “schizophrenic person”: Reflections on illness and the self. Theory and Psychology, 17, 395–420..
Sass, L., & Parnas, J. (2007). Explaining schizophrenia: The relevance of phenomenology. In M.C. Chung, K.W.M. Fulford, & G. Graham (Eds.), Reconceiving schizophrenia (pp. 63–95). Oxford: Oxford University Press..
Shapiro, D. (1965). Neurotic styles. New York: Basic Books.
Shapiro, D. (1981). Autonomy and rigid character. New York: Basic Books.
Shapiro, D. (2000). Dynamics of character. New York: Basic Books.
Stanghellini, G. (2004). Disembodied spirits and deanimated bodies: The psychopathology of common sense. Oxford: Oxford University Press.
Stanghellini, G. (2010). Commonsense, disembodiment, and delusions in schizophrenia. In G. Dimaggio, & P. H. Lysaker (Eds.), Metacognition and severe adult mental disorders: Crossing from basic research to treatment, 134–149.
Stanghellini, G., & Ballerini, M. (2007). Values in persons with schizophrenia. Schizophrenia Bulletin, 33, 131–141.
Stanghellini, G., & Monti, M. R. (1993). Influencing and being influenced: The other side of ‘bizarre delusions’. Psychopathology, 26, 165–169.
Strauss, J. (1989). Subjective experiences of schizophrenia. Schizophrenia Bulletin, 15, 179–187.
Taylor, C. (1976). Responsibility for self. In A. Rorty (Ed.), The identities of persons (pp. 281–299). Berkeley: University of California Press.
Taylor, C. (1985). The person. In M. Carrithers, S. Collins, & S. Lukes (Eds.), The category of the person: Anthropology, philosophy, history (pp. 257–281). Cambridge: Cambridge University Press.
Thalberg, I. (1978). Hierarchical analysis of unfree action. Canadian Journal of Philosophy, 8, 211–225.
Watson, G. (1975). Free agency. Journal of Philosophy, 72, 205–220.
Winnicott, D. W. (1958). The capacity to be alone. International Journal of Psychoanalysis, 39, 416–420.
Wolf, S. (1987). Sanity and the metaphysics of responsibility. In F. Shoeman (Ed.), Responsibility, character, and the emotions: New essays in moral philosophy (pp. 46–62). Cambridge: Cambridge University Press..
Wolf, S. (1993). The real self view. In J. Fischer & M. Ravizza (Eds.), Perspectives on moral responsibility (pp. 151–170). Ithaca: Cornell University Press..
Wolf, S. (2005). Freedom within reason. In J. S. Taylor (Ed.), Personal autonomy: New essays on personal autonomy and its role in contemporary moral philosophy (pp. 258–274). Cambridge: Cambridge University Press.
Woods, W. (1938). Language study in schizophrenia, Journal of Nervous and Mental Disease, 87, 290–316.
References Sass, L. (2004) Affectivity in schizophrenia: A phenomenological perspective. Journal of Consciousness Studies, 11, 127–147. Also appeared in D. Zahavi (Ed.) (2004). Hidden resources: Classical perspectives on subjectivity (pp. 127–147). Exeter: Imprint Academic.
Sass, L. (2007). Contradictions of emotion in schizophrenia. Cognition and Emotion, 21, 351–390.
Acknowledgement
For helpful comments on drafts of this article, I am grateful to Steven Silverstein, James Walkup, Barnaby Nelson, Shira Nayman, Pierre-Henri Castel, Alain Ehrenberg, Saneke de Haan, and Craig Piers.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2011 Springer Science+Business Media, LLC
About this chapter
Cite this chapter
Sass, L.A. (2011). Autonomy and Schizophrenia: Reflections on an Ideal. In: Piers, C. (eds) Personality and Psychopathology. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-6214-0_5
Download citation
DOI: https://doi.org/10.1007/978-1-4419-6214-0_5
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4419-6213-3
Online ISBN: 978-1-4419-6214-0
eBook Packages: Behavioral ScienceBehavioral Science and Psychology (R0)