Phenomenology,
Meaning, and
Metaphor
Keywords: schizophrenia, psychosis, auditory verbal
hallucinations, pathogenesis, and etiology
T
he first commentary that we discuss is
the quite critical one by Thomas and Long-
den (2015). The pertinent question is if the
authors’ criticism hits the mark or if it is simply
off the mark? We will let the reader decide. In the
following, we address some of the most important
problems in their commentary.
First, Thomas and Longden seem to conflate the
concept of pathogenesis (referring to the develop-
ment of a disorder or a symptom) with that of
etiology (referring to the cause[s] of the disorder or
a symptom). We have presented a phenomenologi-
cal account of the pathogenesis of some auditory
verbal hallucinations (AVHs) in schizophrenia
(Henriksen et al. 2015)—an account based on
empirical data derived from in-depth interviews
with numerous patients with schizophrenia (from
which the prototypical vignettes were drawn) and
on theoretical–philosophical reflections. In short,
we describe the temporal and structural vicis-
situdes in a process in which thoughts may come
to be experienced as alien voices, and we draw
attention to certain alterations of the forms of
self-awareness that seem to allow AVHs to mani-
fest themselves in schizophrenia. We make abso-
lutely no claims regarding the possible etiology of
© 2016 by The Johns Hopkins University Press
Mads Gram Henriksen and
Josef Parnas
AVHs. We are inclined to believe that AVHs are
etiologically and pathogenetically heterogeneous
phenomena (Ey 1973).
By contrast, the alternative account offered by
Thomas and Longden concerns only the etiology
of AVHs (or ‘voices’ as they prefer). What they
offer is a strong environmental hypothesis of the
causation of AVHs, conceptualizing ‘voices’ as dis-
sociative mental phenomena resulting from “psy-
chological distress and social adversity” (Thomas
and Longden 2015, 189). In other words, they
propose that if you hear ‘voices,’ then it is because
something unbearable or traumatic has happened
to you in your past. We understand this account
as a standard type of psychological reductionism,
although far less sophisticated than in contem-
porary psychoanalysis (a psychoanalytic account
also offers some structural considerations, e.g.,
by referring to ‘psychological organization’). Ad-
ditionally, it seems that Thomas and Longden are
strongly influenced by the ideas prevalent in voice
hearing networks. Thus, they readily reject both
the very concepts of schizophrenia and of AVHs,
making their criticism even more impenetrable.
They claim a universally valid etiological account
of ‘voices,’ whereas we presented a pathogenetic
account of some AVHs in schizophrenia.
Second, Thomas and Longden refer to the
‘robust association’ between trauma (especially
during childhood) and AVHs (and partly schizo-
194  ■  PPP / Vol. 22, No. 3 / September 2015
phrenia) to empirically support their account.
We fully agree that childhood trauma may be a
risk factor for AVHs and schizophrenia; however,
it must be noted that this evidence stems from
retrospective studies using retrospective reports.
Moreover, inference of causality from such studies
is methodologically risky—association does not
equal causation. A simple observation may help:
although some patients with schizophrenia, who
experience AVHs, have been exposed to child-
hood adversity, trauma, or neglect, other patients
with schizophrenia, presenting similar symptoms,
have not been exposed to anything of that kind.
Moreover, there are also other well-known risk
factors, which Thomas and Longden fail to men-
tion, including a family history of schizophrenia
(the strongest factor), prenatal exposure, perinatal
complications, urban birth or residence, migrant
status, and adolescent cannabis use (e.g., Clarke
et al. 2012; Gejman et al. 2011). In our view, the
authors’ exclusive focus on trauma as the sole
cause of AVHs is far too simplistic and overlooks
the variety of formative factors in the vulnerability
to schizophrenia.
The third problem concerns two interrelated
issues, namely the notion of meaning and the use
of phenomenology. According to Thomas and
Longden (2015), our account is confronted with
a serious problem—as they put it, “[The] problem
with using phenomenology this way is that it dis-
regards the possible meanings of the experiences
of psychosis” (p. 188). We beg to differ. We have
elsewhere argued at length that applying such a
phenomenological approach may enable us to un-
derstand psychotic symptoms in schizophrenia that
traditionally have been considered incomprehen-
sible or bizarre (e.g., Henriksen 2013; Henriksen
and Parnas 2014; Parnas and Henriksen 2013). In
this context, understanding means a pathogenetic
or developmental reconstruction of the psychotic
phenomena that enables the patient’s experiences
to appear less enigmatic, and we suggest that
this can be achieved by eliciting the generative
disorder that prefigures and constrains the range
of symptoms that may emerge. Such reconstruc-
tion, rather than hindering, may in fact facilitate
a more individual and biographically coherent
self-understanding on the part of the patient. This
way of finding unity and meaningful coherences is
of course different from that proposed by Thomas
and Longden, which seems to prescribe the mean-
ing of psychotic experiences by a universal law-like
necessity: something unbearable happened to you
once and this is why you hear alien voices today.
Finally, we need, however briefly, to address a
rather odd claim by Thomas and Longden, namely
that our account is in “conflict with the spirit of
the work of Merleau-Ponty and Heidegger” (p.
187). This vague reference to a “spirit” is unfor-
tunately a quite generalizing and formless claim.
Seemingly, it has something to do with the way
we analyzed the patients’ experiences, which, ac-
cording to Thomas and Longden, is divorced from
the contexts of the patients’ life histories, which,
on their account, is the only source of meaning.
We do not accept their monopoly on the meaning
of psychotic experiences or their reductive, etio-
logical account of AVHs. Moreover, Thomas and
Longden find it significant that we make no refer-
ence to Heidegger’s notion of being-in-the-world.
However, they have overlooked that we have, in
fact, elsewhere explicitly discussed Heidegger’s
notion of being-in-the-world and shown how it
can be fruitfully applied to grasp basic subjective
experiences in schizophrenia (Henriksen et al.
2010). Somewhat ironically, the ‘faithful’ read-
ings of Heidegger and Merleau-Ponty, offered
by Thomas and Longden, are to some extent at
odds with the ideas presented in these works.
For example, Heidegger (2007) did not ‘set out a
general ontology,’ but struggled to uncover time as
the meaning of Being (Sinn von Sein). When they
argue that Heidegger’s determination of Dasein
as history “opens up the possibility of thinking
about human lives in narrative terms … as having
a beginning, a middle and an end” (Thomas and
Longden 2015, 188), they apparently fail to realize
that Heidegger’s determination is ontological, not
ontic in nature (Heidegger 2007).
The second commentary by Allison-Bolger
(2015) is quite interesting, touching on many cen-
tral questions, not only relevant to our account,
but broadly to the disciplines of psychiatry, psy-
chology, and anthropology, namely, how should
we interpret the statements of our patients? She
argues that it “is an established opinion in psy-
 Henriksen and Parnas / Phenomenology, Meaning, and Metaphor  ■ 195
chopathology that patients mean what they say
literally” (p. 183), and that we endorse this posi-
tion, when we, in her phrasing, claim, “that we
should not understand their complaints as ‘merely
metaphorical’” (p. 183). According to Allison-
Bolger, our account rests on this assumption. She
accentuates her point, claiming that we say that the
patient’s statements “should not be understood as
metaphors” (p. 183, our italics), and she describes
our interpretation of the patients’ remarks as a
‘literal reading.’ On her account, we therefore risk
misunderstanding what the patient intended to say.
There are several ways of responding to these
comments. First, her argument seems to be a straw
man. We also deplore a prevalent tendency among
psychiatrists not to pay sufficient attention to the
issues of expression and meaning. At no point
do we claim that patients’ statements should be
understood literally and not metaphorically. When
we suggest that the complaint of ‘living in the head’
should not be understood ‘merely metaphorically,’
our phrase does certainly not rule out the possibil-
ity of also understanding it metaphorically and,
more generally, that metaphor always conveys
certain lived aspects of the pre-linguistic experi-
ence. Therefore, we do imply that this particular
complaint might by meant in a more literal sense
than most of us would be inclined to expect and
that this is something to be aware of when encoun-
tering this complaint. In brief, Allison-Bolger’s
arguments for attributing to us an exclusively
‘literal’ approach are not textually justified and
she seems to be attacking a straw man.
Second, we agree with Allison-Bolger that “we
don’t only speak either literally or metaphorically”
(p. 184), and with her idea that we should always
try to understand what a patient means with a
given statement before explaining it or, alterna-
tively, identifying it as a certain type of complaint
(e.g., delusions or hallucinations). A metaphor
is of course not just a metaphor and the role of
metaphor in language, understanding, and, not
least, psychopathology has always been a vener-
able topic for psychiatric phenomenology (Blondel
1914). In fact, this consideration is a quintessential
aspect of the EASE interview (Parnas et al. 2005).
To examine if, say, loss of thought ipseity (item
1.2), spatialization of experience (item 1.8) or
audible thoughts (item 1.7) is present, it is not
enough that the patient simply affirms the inter-
viewer’s question; the patient must herself come up
with concrete examples of such experiences, and
only upon further questioning, clarifying, through
active dialogue, what she means with her examples
and the nature of these experiences, the interviewer
may score the relevant item as present if it fulfills
the item definition (Nordgaard et al. 2013).
Acknowledgements
Funding: M.G.H. is funded by the Carlsberg
Foundation (#2012010195).
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