Philosophy, Psychiatry, & Psychology

The 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 development 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 phenomenological 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 vicissitudes 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 manifest themselves in schizophrenia. We make absolutely no claims regarding the possible etiology of 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 dissociative mental phenomena resulting from “psychological 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 contemporary psychoanalysis (a psychoanalytic account also offers some structural considerations, e.g., by referring to ‘psychological organization’). Additionally, 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 schizophrenia) [End Page 193] 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 childhood 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 mention, 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 disregards 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 understand psychotic symptoms in schizophrenia that traditionally have been considered incomprehensible or bizarre (e.g., Henriksen 2013; Henriksen and Parnas 2014; Parnas and Henriksen 2013). In this context, understanding means...