SASS / PATHOGENESIS, COMMON SENSE, AND THE CULTURAL FRAMEWORK
Pathogenesis,
Common Sense, and
the Cultural
Framework:
Commentary on
Stanghellini
I
T IS A pleasure to comment on Giovanni Stang-
hellini’s vivid and comprehensive article, “Psy-
chopathology of Common Sense,” in which
he presents a synopsis, interpretation, and exten-
sion of a number of key ideas from the tradition
of phenomenological psychiatry. In the article,
Stanghellini offers a way of classifying a wide
range of schizophrenic abnormalities while also
drawing our attention to two often neglected
aspects of schizophrenia: the role of the patient’s
intentions and attitudes and the foundational
importance of the social or interpersonal ground-
ing of human experience and knowing. An espe-
cially valuable feature is the inclusion of exten-
sive case vignettes to illustrate the more abstract
points and help one see their application in clini-
cal and therapeutic contexts.
I am broadly in agreement with the perspec-
tive on schizophrenic psychopathology offered
here. I do wish, however, to point out what
seems to me to be one exaggeration or perhaps
inconsistency in Stanghellini’s argument. In addi-
tion, I will question some aspects of his charac-
terization of previous work on the phenomenol-
© 2002 by The Johns Hopkins University Press
■ 219
Louis A. Sass
ogy of schizophrenia, including my own. Finally,
I will mention evidence from cultural anthropol-
ogy that is consistent with Stanghellini’s argu-
ment and consider questions that his interesting
portrayal of schizophrenia might raise concern-
ing the relationship between this condition and
the social or cultural order.
Stanghellini clearly wants to argue for the
central importance of intersubjectivity; there
seems, however, to be some inconsistency in the
precise status he attributes to it in this paper. In
the first pages of the introduction, Stanghellini
states that he sees the interpersonal or intersub-
jective dimension as having a primordial or caus-
ally primary status: “ . . . I argue that the crisis of
common sense is in fact a consequence of a more
fundamental disturbance of intersubjectivity,” he
writes, “i.e., that the primary disturbance is not
in the attunement between subject and object,
but in the attunement between subject and sub-
ject (or self-other attunement)” (p. 201). “. . . the
direction of causality seems to go from interper-
sonal difficulties to the schizophrenic syndrome
as a whole” (p. 202). He describes one’s sense of
presence and of reality as “products of intersub-
jectivity” (p. 203).
Later, however, Stanghellini appears to adopt
a more agnostic standpoint. Thus he notes at one
220 ■ PPP / VOL. 8, NO. 2–3 / JUNE–SEPTEMBER 2001
point that certain “disorders of basic cognition”—
what he calls “sensory level disorders”—could
play a primary role by “interfer[ing] with the
perception of external and especially social reality”
(p. 208). Somewhat later, he mentions the possi-
bility that a disorder of the perception of “one’s
own bodily sensations, may be involved in the
pathogenesis of defective attunement (i.e., inter-
corporeality) and of a deficit in social function-
ing” (p. 215). In the latter passage, Stanghellini
acknowledges that the causal relationships be-
tween disorders of ipseity, disorders of attune-
ment, and antagonomia, in fact, are not current-
ly understood and therefore require further
empirical investigation.1 I am not sure how far
Stanghellini intends to go in emphasizing the
primacy of intersubjectivity. In these later pas-
sages, he appears to be backing away from the
strong claims with which he begins. Actually, I
think he is wise to do so; for although Stanghell-
ini does an excellent job of arguing for the prom-
inence of the interpersonal dimension, I do not
think he has presented any real evidence or argu-
ment that would demonstrate that it has the
pathogenetically primary role.
The whole question of the relationship and
relative primacy, among different aspects, fea-
tures, or processes characteristic of a particular
form of mental disorder is, it seems to me, a
vexed and obscure issue in the field of psychopa-
thology in general. I have not found any work of
phenomenological psychopathology that offers a
succinct and clear synopsis of these issues. In a
recent article (Sass and Parnas, submitted), Josef
Parnas and I have had to address, albeit briefly,
the forms of phenomenological explanation rele-
vant to psychopathology (a future article will
treat this issue in more detail). There we distin-
guish relations of causation from relations involv-
ing a kind of mutual phenomenological implica-
tion. As we note, disturbances of hyperreflexivity
and of ipseity, for example, need not be con-
ceived of as involving distinct processes that are
in causal interaction; they may be more accurate-
ly conceived of as different facets of a single
phenomenological alteration that is simply being
viewed and described from two different angles.
Similarly, what Stanghellini refers to as “inter-
subjectivity” should not, perhaps, be conceived
as a distinct process but as an aspect that could
be considered to be “equiprimordial” (Heideg-
ger 1962) with other aspects of mental life.
Another more widely recognized fact is that a
phenomenon that originates as a causal outcome
or byproduct of, or as a defensive compensation
for, something more primary can itself take on a
pathogenetic role by bringing about further de-
velopments that occur either as causal conse-
quences or in some kind of defensive or compen-
satory fashion. In a recent article (Sass 2000), I
try to show in detail how particular phenomena
involving hyperreflexivity can play a number of
different kinds of causal roles. A patient may, for
example, engage in forms of introspective self-
awareness as a coping or compensatory mecha-
nism—a way of attempting to get control over a
sense of inner fragmentation or dissolution. This
very attempt, however, can take on a life of its
own and eventually bring on consequences that
are counterproductive. The patient may, for in-
stance, ruminate on his own ruminations to the
point of a total loss of meaning. He may devote
so much attention to detail that the sense of a
unified field of experience is destroyed. Mental
life may become tortured and painfully self-con-
scious, ultimately fragmenting itself from within.
“My downfall was insight,” explained one young
man with schizophrenia, “too much insight can
be very dangerous, because you can tear your
mind apart.” “Well look at the word ‘analysis,’ ”
he said on another occasion. “That means to
break apart. When it turns in upon itself the
mind would rip itself apart. Once I started de-
stroying [my mind], I couldn’t stop” (Sass 1992,
337–8). In one passage, Stanghellini draws a
contrast between my own treatment of hyperre-
flexivity as a “destructive” process and Minkows-
ki’s treatment of hyperrationality as a process of
“coping” (p. 212). However, (as I think Stang-
hellini would agree) it is quite possible for a
given process to play both a destructive and a
coping role at the very same time.
My overall point is to emphasize the complex-
ity of pathogenetic relationships and the impor-
tance of avoiding an overly simple causal model
or causal attribution. Clearly, the tracing of pre-
 SASS / PATHOGENESIS, COMMON SENSE, AND THE CULTURAL FRAMEWORK
cise pathogenetic sequences is no easy task. We
must recognize that to demonstrate that a given
phenomenon—such as interpersonal dis-attune-
ment (or hyperreflexivity, for that matter)—can
or even does play a pathogenetic role, is by no
means the same as demonstrating that it is, in
fact, the primary causal factor.
I must also take issue with Stanghellini’s state-
ment or implication that the interpersonal and
attitudinal dimensions of schizophrenic psycho-
pathology have been neglected by what he refers
to as “established” theories or common assump-
tions in the phenomenological tradition. He re-
fers to “analyses of the disorders of phenomenal
self [that] catch only some dimensions of schizo-
phrenic vulnerability, since they mainly focus on
the pathological changes in subjective experience
of an isolated self and disregard the fact that the
self is not purely personal” (abstract). In his
paper, Stanghellini cites my book, Madness and
Modernism (1992), as the source for the notion
of hyperreflexivity. With apologies for adopting
such an egocentric approach, I would point out
that the longest chapter in that book is in fact
primarily concerned with the interpersonal di-
mension, and it draws heavily on the work of
previous phenomenologically oriented psycho-
pathologists. The title of that chapter, “The Sep-
arated Self,” is meant to be an homage to R. D.
Laing’s important book, The Divided Self, which
pays much attention to the ways in which schiz-
oid and schizophrenic persons become dis-artic-
ulated from the social and cultural context. Oth-
er works that emphasize this dimension include
Blankenburg (1991), Rümke (1990), Minkowski
(1927), and Binswanger (1987). In Madness and
Modernism I also address, very explicitly, the
volitional or intentional aspects of schizophrenia
that Stanghellini refers to as “attitudinal.” The
first substantive chapter (Sass 1992, chap. 2:
“The Truth-Taking Stare”) concludes with an
extensive discussion of this issue, which I label
the “Act or Affliction?” question (68–74); and
the issue is then taken up repeatedly in subse-
quent chapters. One of the main reasons I used
modernism and postmodernism as sources of
analogies was that I wanted to show that schizo-
phrenic experience and expression can be illumi-
■ 221
nated by being compared to phenomena whose
intentionality and meaningfulness are widely ac-
knowledged. There is, however, also the danger
of overemphasizing intentional factors; it would,
of course, be misleading to present the relevant
forms of thought or action as being entirely voli-
tional in nature.
Dr. Stanghellini makes an important point in
calling our attention to the significance of the
“attitudinal” factors that he refers to as “hyper-
tolerance of ambiguity” and a “skeptical attitude
toward common sense” (p. 202), and which he
describes as involving a “deliberate epistemolog-
ical attitude” (p. 213). In three chapters on
thought and language in Madness and Modern-
ism (chap. 4, 5, 6), I explore these and related
trends in schizophrenia-spectrum conditions by
comparing them to certain esthetic and existen-
tial orientations as well as philosophical atti-
tudes characteristic of proto-modernist, modern-
ist, and post-modernist culture, including the
poetry of Mallarme, the humor of Alfred Jarry,
and the anti-philosophical theorizing of Jacques
Derrida.2 Even in the case of these three cultural
figures, it would be wrong to conclude that such
attitudes or orientations are entirely volitional
products—manifestations of an utterly free and
self-aware existential choice. Every artist or think-
er obviously has certain natural predilections
involving temperamental factors and cognitive
style; his or her sensibility and style are also the
product of deeply sedimented cultural assump-
tions and practices, whose determining and largely
unconscious nature is emphasized by such con-
cepts as Michel Foucault’s notion of the episteme
or Pierre Bourdieu’s notion of the habitus. It
would be surprising if this were not also true in
the case of schizophrenia.
Stanghellini is right to remind us that hyper-
tolerance of ambiguity is an attitude or existen-
tial orientation that is, in part, taken up by the
patient as an intentional act. However, we must
not forget that such an attitude is likely to be
built on cognitive-affective propensities that are
also likely to be part of the person’s constitution
or native endowment or long since acquired as-
pects of personality or cognitive style. The same
can be said of hyperreflexivity: It may involve
222 ■ PPP / VOL. 8, NO. 2–3 / JUNE–SEPTEMBER 2001
quasi-volitional as well as automatic or passively
experienced phenomena (Sass 2000). What is
really necessary is to transcend the dichotomy of
the volitional and the automatic, of the act ver-
sus the affliction account. For even if one were,
in some sense, doomed to a particular orienta-
tion or cognitive style, one might nevertheless
take it up actively and make it one’s own, there-
by animating the style with a certain intentional-
ity. (This, by the way, is not a point with which I
would expect Stanghellini to disagree; his em-
phasis, however, lies elsewhere.)3
In closing, I would like to cite some anthropo-
logical evidence that is very much in keeping
with Stanghellini’s argument and then go on to
raise some issues concerning the relationship be-
tween schizophrenia and culture.
A simple but suggestive confirmation of some
of the cognitive consequences or correlates of a
decline of intersubjectivity or intuitive attune-
ment can be found in research described in Roy
D’Andrade’s book, The Development of Cogni-
tive Anthropology (1995, 212–6). D’Andrade de-
scribes a study in which the anthropologist James
Bolster examined the use of semantic categories
pertaining to different types of manioc plants in
the folk botany of the Jivaro people. What Bol-
ster found was a striking correlation between the
conventionality and the reliability over time of a
given Jivaro informant’s semantic categories. That
is, those Jivaro individuals, whose choice of se-
mantic labels correlated most highly with that of
the group, were also the ones who tended to call
a particular type of manioc plant by the same
name when shown it on a later occasion.
D’Andrade (214) relates this to a word-associa-
tion study that found a correlation between the
commonality or conventionality of an individu-
al’s word-association responses and the tendency
for that individual to give the same associations
to a given stimulus-word when the word is re-
peated on a later occasion (Moran et al. 1964). A
schizophrenic sample was included in the word-
association study, and, interestingly enough, the
schizophrenic subjects produced fewer modal or
conventional responses and were also less consis-
tent or reliable over time in the associations they
gave.
These results, though hardly counterintuitive,
are interesting nonetheless: They suggest that
adherence to group norms may have the advan-
tage of encouraging a certain stability over time
in one’s conceptualizing of the world. D’Andrade
(1995) speaks of the importance of the social
milieu in maintaining our “internal guidance sys-
tems,” noting that goals are inclined to lose their
force without social support (243). It appears,
then, that there may be some important link
between two of the most distinctive features of
the schizophrenic mind: the sheer eccentricity
and the sometimes-kaleidoscopic fluidity or slip-
page that are characteristic of their conceptual or
cognitive style (see Holzman et al. 1986; Sass
1992, 124–34). We can, of course, interpret this
in a variety of ways. It is possible that social dis-
articulation might rob a person of the consistent
guidance and feedback, largely unnoticed, that
would normally keep thoughts in line. Another
possibility is that a more intrinsic tendency to-
ward cognitive slippage or hyperreflexivity might
actually make it difficult to stay embedded in the
conventional.
Cultural assumptions and practices play a cru-
cial role in organizing our thoughts and orient-
ing our actions, but they do this in a largely
unconscious way that can be disrupted by exag-
gerated forms of self-awareness. Another psy-
chologically oriented anthropologist, Bradd Shore
(1996, 107) draws our attention to one potenti-
ality that the sedimentation or unconscious em-
bedding of cultural assumptions allows: the pos-
sibility of a paradoxical form of “marginal play,”
whereby a person draws attention to a cultural
frame by defying it or otherwise calling it into
question. Most societies have their quasi-ritual-
ized, often carnivalesque ways of doing this, their
institutionalized meta-moments when standard
hierarchies are overturned and the usually un-
spoken comes to be said aloud.
Schizophrenics, I would argue, have a particu-
larly fraught relationship to marginal play. As
Stanghellini’s intriguing case examples illustrate,
the alienation and hyperreflexivity characteristic
of such individuals often seem to give them, or at
least many of them, a special interest in the
normally unseen foundations of human behavior
 SASS / PATHOGENESIS, COMMON SENSE, AND THE CULTURAL FRAMEWORK
(e.g., patient P.S.’s interest in an ethological per-
spective). Many such individuals may, in fact,
develop a kind of special insight into the arbi-
trariness and consequent absurdity of social con-
ventions; they often have a natural affinity for
the marginalized and self-marginalizing edges of
society. Often they seem to adopt what seems, in
any particular society, to be the “path of most
resistance” (Schooler and Caudill 1964, 177),
and they may adopt a stance of hyper-autonomy
and contrarianism that can seem the epitome of
willful defiance (Sass 1992, 108–15). This con-
trarianism may involve an active taking-on of an
outsider-role, but this role is also likely to be
imposed on them by an ostracizing society. In-
deed, there is also a sense in which these atti-
tudes and cognitive tendencies can be more af-
fliction than act—less a matter of being motivated
to hear the beat of a different drummer than of
simply being incapable of staying in step. Fur-
ther, the meta-moves and frame-breaking in which
such individuals so readily engage may also be
rather beyond their control—not so much a game
they play as a kind of uncontrolled slippage that
plagues them. Whereas the phenomenologist, even
in his armchair, must make a concerted effort to
achieve this bracketing and the unnatural illumi-
nation that accompanies it, for the schizophren-
ic, the unnatural falling-away happens all too
easily, even in the midst of attempts at practical
action (see Blankenburg 1991, 115–6).
Notes
1. In his abstract and conclusion, Stanghellini de-
fines ipseity as “the vanishing of the feeling of distinc-
tiveness between the self and the outer world.” A
better definition of ipseity (see Henry 1973; Parnas
2000) would emphasize something that can be consid-
ered even more basic than this sense of boundary,
namely, what Stanghellini elsewhere in his article de-
scribes as “the sense of existing as a subject of aware-
ness” as opposed to a “fuzziness and feebleness of my
being present” (p. 203).
2. One point to bear in mind is that this hyper-
tolerance often involves not merely a drifting among a
variety of mental contents, but a slippage among differ-
ent orientations or frameworks of perception and un-
derstanding (see Sass 1992, chap. 4). This, in fact, may
be one feature that differentiates schizophrenic from
■ 223
other forms of abnormal thinking, such as that typical
of mania (which, I think, is a point that is neglected in
some of the work that Stanghellini cites, e.g., Schwartz
et al. [1997], who present a neo-associationistic inter-
pretation of schizophrenia).
3. Stanghellini seems to acknowledge this same point
in his discussion of his patient E.B., a young man with
schizophrenia who exerts himself “to voluntarily con-
nect the perception of the meaning of one object with a
trend of associated meanings. In this case,” writes
Stanghellini, “an enlarged horizon of meanings does
not simply reflect a forceful train of more or less
relevant associations, but reveals a deliberate attempt
to enlarge one’s own mental capacities to transcend the
commonsense world” (p. 213).
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