The Axiological Structure in Psychosis

Abstract

In this chapter the value structure will be described as one of the essential existential foundations from a phenomenological perspective. Psychosis could be understood as the result of structural modifications of the self in anchoring the lifeworld. These modifications would mainly be due to failure in the construction of intersubjectivity and therefore of the common sense or basic intuitive tuning of the social world. This failure precisely involves the axiological component of psychotic being-in-the-world, so its description will be emphasized, along with its peculiarities and similarities to other ways of functioning of this axis of values, both adapted and pathological. This approach will be observed in terms of its therapeutic possibilities for the improvement and removal of the so-called negative symptoms. These are the warhorse for true recovery, understood as a personal and unique process for the clarification, development, adjustment of attitudes and values, affectivity and skills in social roles that can lead to a satisfactory and hopeful way of life. Those interventions that try to create a new existential situation or being-in-the-world will be described.

1. Introduction

1.1 Theoretical foundation

Attempting to summarize the value structure in psychosis first requires defining three concepts: structure, values, and psychosis. Structure is understood as the relationship maintained between the different parts of a whole or the way in which said parts are organized in relation to the whole. For the purposes of the subject addressed in this work, the parts which we are concern with would be values. Their structure would determine the whole, which, as will be explained, is a reference to the human person [1, 2].

What are values? According to axiology—the philosophical discipline based on the value of things—values can be defined as those aspects that give meaning to things. Together, they will determine the behavior of an individual, depending on the importance they possess. Thus, values can be conceptualized as those attitudes whose function is to regulate our behavior. Surprisingly, however, despite being a key aspect in the construction of the individual, values have scarcely been studied in the field of psychosis [3].

The final element to define would be psychosis. The definition presented here will not address the well-known formal diagnostic systems (DSM-5 and ICD-11), albeit they are also classically discussed [4]. Instead, following a more phenomenological description, psychosis is understood more as a peculiar construction of the being-in-the-world, whose essential manifestation would be the “loss of common sense” or of natural evidence, caused by, among other factors, focusing on psychological processes that go unnoticed in other people [5, 6].

In this sense, it is also worth considering that the positive symptoms in psychosis (e.g., hallucinations, delusions, grossly disorganized or catatonic behavior) could well be the manifestation of more basic characteristics related to negative symptoms. Apathy, abulia and demotivation could in turn be the result of the lack of anchoring and fitting in with to the interests or social values of other people. In fact, it could be said that these negative symptoms are not simply located in the realm of affectivity; instead, they would exist as result of the specific relationship that the individual maintains with the oneself and towards the world. Both are not given separately or added but are to be understood as the basic being-in-the-world.

From this perspective, psychosis would be understood as the result of structural modifications of the self in its anchoring in the world-of-life, given the flaw in the construction of intersubjectivity and therefore common sense, understood as the basic intuitive tuning with the social world [6, 7].

1.2 Therapeutic approaches

In fact, the therapy session itself, not focused on the symptom, is the context that would present an opportunity for the development of intersubjectivity. The patient would have the chance to learn to feel what it is like to have things in common with others and experience feelings of acceptance and everyday life. Not in vain, the self-in-company is the barometer of the being-in-the-world [5].

In this regard, it is noteworthy that in recent years a great deal of therapeutic efforts made among patients with psychosis and severe mental disorders have resulted in strategies aimed precisely at attempting to restructure life’s sense and, therefore, values. This approach leads to a more fulfilled life experience. For example, in the approach known as Open Dialog [8], listening emerges as a more important variable than the intervention method; it specifically allows the reduction of uncertainty while also revaluating the social support system. This grants greater responsibility to both the family and the patient to discuss life situations and to manage their lives more confidently.

Similarly, another alternative with phenomenological roots, practiced by mental health patients on their own, is the Power Threat Meaning Framework [9], a psychiatric diagnosis process proposed by the Division of Clinical Psychology of the British Psychological Society. In this case, symptoms would be understood as survival strategies against adversities and their meaning would always be related to life circumstances. Faced with threats (in relationships, identity, values, discrimination, emotions) generated by negative impacts of power (biological, coercive, legal, economic, cultural, interpersonal, or ideological forces), the patient will attempt to assign them meaning (beliefs, feelings, and physical reactions) and respond to them. These responses may include aggressive behavior, unusual sensory perceptual or cognitive experiences, catatonia, dissociation, hearing voices, weakness, affective flattening, indifference, submission, paranoia, panic, depersonalization or derealization, among others. The aim of this framework is to gather strength, enhance the socio/family support resources of each patient, in order to empower them and rebalance their life according to the values of justice, equity, personal safety, belonging, direction and agency. In this way, this approach would help patients to have an existence with sense, meaning and purpose. The above examples involve the generation of contexts that can revaluate existence, beyond traditional bio-medical framework.

In addition, it can also be proposed that delusions, alterations in discourse, the experience of corporeality and the temporality, paranoidal or schizoidal ways of interacting would be —once the phase of confusion had been overcome—completely self-evident to the psychotic person. This would be their personal “anchoring in the life-world”. The need to anchor oneself —to be anchored—would imply that these phenomena would be evident to those individuals who lack common sense or the sense of belonging to the world of others. In fact, the human person model by [1] emphasizes the idea that the psychotic experience is a prototypically universal effort to construct a valuable and authentic sense of the self.

1.3 Life experiences of psychotic patients

However, any specific characteristics would stem from the complex experiences of the psychotic self which distance it precisely from certain socially adaptive values. They would therefore become barriers against achieving an acceptable level of wellbeing. Aspects related to work, sentimental relationships, raising a family, academic development and economic autonomy, leisure and social activities, health and general wellbeing tend to be either extraordinarily deficient or simply inexistent. It seems quite logical then that severe cases of psychosis appear during adolescence, precisely at a critical moment in the construction of the self. This development of the self would thus take place in the turbulent waters of the different conflictive roles (even ambivalent and antagonistic) which the individual will face as they evolve as a person [2].

Late-life psychosis also tends to develop in conflictive contexts or in complex existential transits, which would require a personal transformation not exempt from difficulties and risks. The Heideggerian concept of the human being as a transient and rational being and, therefore, narrative would imply the idea that living is always difficult. Overvaluation of the inner experience would result in an ontological catastrophe [10]. This private experience is a continuous flow of events, in which the event (“what arrives”) impedes any feeling of having completely experienced what occurred [11]. This prompts the individual to experience events as not their own (since they are not possessed, and instead simply appear). Such events tend to be the object of overvaluation or hyper-reflexibility, whereby psychotic self-reflection is the “active stinger of the soul” [12]. In addition, this hyper-reflexibility occurs in different psychopathological conditions [13].

The life experience of certain psychotic individuals would therefore not cease to be a continuous and complex component. And that idiosyncratic environmental and behavioral history is what influences the experience of remembering, thinking, or feeling in the present. This refers to the world in which people exist; this world would arrive before the ideas created about it. This implies, in the words of Heidegger, that the individual must first remain “under the empire of Others”.

The predefined types/models of life or values can be achieved, lived, understood, or accepted or not. It must be noted that values, as the guiding horizon which human beings migrate towards, and are therefore ingrained in them as psychological beings, cannot be reduced to a process of reasoning. Values cannot be accessed analytically because they are there (whether we want them or not). Thus, it is deduced that values will naturally be conditioned by different social-relational aspects.

1.4 Values of psychotic patients

It is important to consider some of the values engrained in the world of a person with psychosis when analyzing values. As previously discussed, their world is phenomenologically different from the common-sense world. It is normally associated with a sense of eccentricity or exceptional nature, which are believed to be “given”, not chosen. In fact, it is observed that the axiological structure in psychosis features a preeminence of eschatological values that give great meaning to the life experience of patients. Thus, the feeling of idionomia or exceptionality and radical uniqueness is quite common [3]; the psychotic individual gives a meaning to events upon which they build a special –exceptional— identity. The events regulate their consciousness and life action, orienting them towards metaphysical existential planes, perhaps with a different mission or purpose from the objectives or goals common to their social environment. In Jaspers words [12] “the patient is personally important as a discoverer … his days are filled with meaningful mental work”. These eschatological values will be the center of gravity upon which the psychotic individual will sustain their actions and consciousness. This will remove them from other constitutive values which will probably remain frozen due to the enormity of their psychotic experience.

This disconnection from the pragmatic life and the distancing from the social-family context prevent the psychotic individual from learning essential lessons for interacting with the world. This peculiar case of self-absorption is common in modern societies [14]. According to Taylor [15], the dissolution of moral horizons, as a paradigm of modern society, would leave life with no ground to anchor itself onto given the loss of the sense provided by said horizons. In this way life could become what Nietzsche would called “a pitiful comfort” [15].

For example, a value that is usually common in a person with schizophrenia is spirituality. Their urgency to show it to others is common, so it is shared with everyone. As the objective of proselytism is to be praiseworthy a priori, it can also be characterized by a lack of empathic intuition; possibly generating a history of social rejection. These idiosyncratic values should not be easily confused with abnormal beliefs. Instead, they must be recognized as the world of the person in order to be modulated or adjusted in therapy [16]. This adjustment process would help the patient to untangle themselves from this egoic existential position. In turn, self-reflexivity would partially cease, allowing them to go beyond the oneself. This would result in an axiological reconstruction of the self by the Self-for-Others. The goal is not to invalidate the spiritual proselytism position, which is legitimate (we must remember that eschatological missions are not chosen sensu stricto, but are experienced as given), but rather to learn to experience sharing life, with no other function than to being-in-the world.

1.5 What patients suffer from

A common observation in the literature on the social integration of individuals with acute psychosis is the existence of severe problems with socio-labor insertion, intimacy, interpersonal communication, and sexuality. This results in a high level of suffering, which is substantially reduced when changes take place in these aspects [17]. The issue is that the lack of social experiences (from avoiding rejection, stigma, being misunderstood, etc.) impedes learning; it also complicates personal orientation towards other personal values. These are precisely the values which could be addressed at certain moments of the therapeutic process.

Survival against stigma, exclusion, and failure, due to the limitations that patients with psychosis suffer from, is a very complex situation. Competing within social function frameworks characterized by the paradigms of individualism and competitiveness is a serious problem, whereby achieving a valuable identity is a very difficult accomplishment. Therefore, it is quite likely to experience feelings of failure, inadequacy, shame, and exclusion, which are indeed forms of personal suffering [9].

Axiological structure will always involve a relationship of the world of the person with others. It involves social values that do not depend merely on individual decisions or processes; they are as much a part of the individual’s difficulties and interests as the actual characteristics of their world. It must be noted that the world is lived on occasions as a whole, making it important to reconstruct the “real” or objective world, which would include friends (probably limited in number), family (generally highly conflictive) and the general population (with high levels of stigma, social distancing and rejection). We must bear in mind that the clarification of the value system is not an analytical dissection.

The “existential ground” where the ethical-moral structure is generated is not a series of items or reasons [15]. It is evident that this structure can and must be chosen, fully committing to the direction that each human being must take in their life. However, it should be noted that axiological structure is already given to us in the world we exist in. Thus, this existential structure of the world-out-there should also be clarified and wholeheartedly accepted.

It is also important to bear in mind that certain values could be conflictive in personal development. Some components of modern culture, whose maxim is self-realization and therefore emphasizes being “true to oneself”, could specifically reinforce individualism and solipsist thinking. But this occurs not only in psychosis; eating disorders are an example of characterological formation based on perfectionism, control, and excessive individuation. Loyalty to that structure of egoic values, which can be useful on occasions, certainly limits and stifles existence itself [18]. Life could become clogged by a blindness to be “someone exceptional” (It will be pointed out, therefore, that any therapeutic effort should be directed to achieve a certain psychological flexibility that allows relativizing loyalty to this private world, above all if that position, both stubborn and defensive, distances the patient from the ordinary world of life).

2. Working with the axiological structure

2.1 Therapeutic dialog

In phenomenological approaches, it is understood that therapeutic sessions need not merely involve a logging of symptoms. Even initial phases, more focused on evaluation and establishing connection, are potentially valuable and enlightening moments. They can be used as opportunities to search for meaning and recognition – key moments for understanding and clarifying the value structure – from which a great deal a person’s experience and actions originate [16].

As previously discussed, the therapeutic relationship itself is a magnificent opportunity to create a meaningful relationship. Even when listening and dialog first begins, contributions can be made towards developing a more robust, pre-reflexive self-awareness [19]. More than being in the presence of the contents of consciousness, it is a form of being that comes before them. To achieve greater existential adjustment, a dialogical transformation must occur as living is tantamount to being-in-the-world. Intersubjectivity is enhanced during the process of mutual recognition, which is such a convulsive aspect of the psychotic experience. In this way, the value structure that moves the person can be understood, making it possible to equip patients with greater psychological flexibility. This will be necessary to both identify values and reveal the common conflicts between them.

The key is, if axiological structure regulates behavior, then its adjustment will allow greater empowerment for a better existential commitment. The literature establishes that psychological recovery among this population refers to establishing commitments, which must focus on constructing a life with meaning, as well as a positive sense of identity. According to [20], the experience of oneself must be based on hope and self-determination. The therapeutic process encourages hope, redefines the identity based on an existential sense and helps the patient to take responsibility for their recovery. This must be approached as an ethical-moral orientation, that is, as a philosophy or life orientation [21]. Therapeutic progress is more than the reduction of positive symptoms; it is a way of being in front them, in front oneself and in front of the world-of-life.

2.2 Clarification of values

However, this world is difficult though because, as Jaspers states, living is a “controversy with the world”. There is always difficulty when reorganizing the value structure, whether addressing the level of confusion, disinformation, or disorganization that the psychotic individual has over themselves. Yet, it is important to highlight one of the key life experiences in the existence of a person with psychosis: fear and suffering, in either the present (oppression, anguish, confusion, stigma) or co-present (avoidance of intimacy, apathy, laughter out of context, metaphysical stubbornness, distancing from the world).

An additional difficulty in the value identification process tends to be the defensive disguising of intense malaise. That co-present fear, hidden or even buried in cognitive-emotional paralysis or in one’s own self-absorption, needs to be lived and made conscious so it may be elaborated, understood, and accepted. This is a basic therapeutic condition that makes it possible to advance beyond the unrevealing of personal values.

Even apathy could be understood as a way of being. The function of this way of being-in-the-world would provide a sort of anesthesia for feeling. When a feeling is incomprehensible, unmanageable, or experienced with strangeness, it is to be expected that they will flee from it. The proposal would be to face these phenomena of living; everything has a purpose, meaning and function. The conflicts derived from the experience of fear allow more effective access to the world of values and their personal worth [9].

If the experience of constructing a sense of the self is eminently intersubjective, it is necessary to create non-invalidating meeting spaces, both in the therapeutic setting and in the formation of natural groups. Experiencing identity includes an axiological structure that must be identified to produce a practical self-knowledge that allows the patient to know how to direct their own life. In this sense, it is worth noting that discussion about the meaning of values benefits from a natural framework, featuring, for example, the participation of more therapists, mutual support groups and family, as in the Open Dialogue approach [8].

Giving the patient with responsibility implies respect for their opinions and their participation throughout the entire process. There is evidence of a therapeutic benefit showing that clinics help to generate different perspectives in which these values in conflict can coexist [22].

2.3 Values and therapy

Thus, therapeutic approaches that could offer an opportunity to identify axiological structure in this population, observe conflicts between the values at play and empower the psychotic patient to deal with obstacles in order to have a life committed to said values, would be those which:

• Seek to capture subjective aspects, namely, the phenomenological experience of the person, removed from psychopathological categories.

• Observe the complexity of life itself and explore feelings, values, personal meaning and experience.

• Accompany the patient in the difficult commitment of choosing their life, accepting the unfinished aspects of their life project.

• Disentangle from their mental processes when self-reflexivity fails to help them transcend.

• Allow ambiguity, as this will teach the patient to tolerate it.

• Successfully manage to make therapeutic contact truly meaningful, creating a comprehensive space that allows patients to feel and do from within themselves; therapist and patient can always present interpretations from the being-in-the-world of the patient (their self and the particular circumstances).

• Allow the patient to experience desperation, in order to understand their stagnation and the feeling of blocking or impairment of the horizon of their future; only from there can the patient collaborate in their own activation towards life, when that is precisely their goal.

• Follow the idiosyncratic scripts of life and that which occurs in therapeutic here-now relationships, rather than prejudicial constructs.

The therapist will be an example of Other in the relationship history of the patient; this will be crucial to the change process given the importance of Others in the construction of the person, as previously explained. For this reason, it will be necessary to address the basic components of the therapeutic session: material production (essentially verbal behavior, but other types of interpersonal behaviors as well, of course), analysis (essentially comprehensive) and the therapeutic relationship (alliance and closeness).

All resistance will be understood as kinds of behavior which make attempts at experiential avoidance. It will be necessary to understand and respect them so they can be addressed when the psychotic individual is ready. In this way will be reminded that these behaviors function as protective strategies that have been assigned meaning.

The change in therapy should not be directed to stop being who one is, but to live with another perspective in the face of the challenges of one’s own existence. Some of these challenges are the construction of a valuable identity and the search for meaning of what happens. And this will always be done on the fundamental basis of the person: the axiological structure of him.

3. Conclusion

The phenomenological perspective on how to understand psychotic problems makes it possible to stay ahead of phenomena precisely as they occur. Doing so avoids prejudiced constructs that obscure the there-given [23]. It eliminates representational aporias and mechanistic paradigm removing them from the experiences of patients with psychosis. In this way, models focused on the human person [1, 2] understand psychotic experiences as phenomena linked to normal psychological development.

People with psychosis will make a great effort to construct a valuable sense of themselves. They understand themselves according to their life experience, in which they construct their social identity and their self in a context; this is the being-in-the-world.

While making this effort, their behavior would deviate from practical actions in life, receiving responses of rejection, stigma, and failure, keeping them even further distanced and absorbed in their private events. Their axiological structure would remain in a state of adolescence or frozen.

The therapy process could help to clarify and endow the patient with more adaptive personal values. It is necessary to provide and find therapeutic settings that allow the meaningful experience of identity to be valuable, reconnecting the patient with the world-there-given as a horizon. It is important to make the transition from the prototypical monological life experience of schizophrenia to a dialogical one. The phenomenological approach is undoubtedly one of the most encouraging comprehension and intervention perspectives for this type of mental health problems. It is responsible for verifying that the recovery of negative and emotional symptoms, as well as the emotional component of psychotic experiences, are related to socio-community functioning and obtaining a valuable life experience [24].

The phenomenological perspective would also be at the base of the new movements in mental health. The Open Dialogue or Hearing Voices approaches emphasize the experience of the person and the problematic experiences. They allow to understand them in the social and family context. The processes of psychological change are related to present values.

Likewise, in phenomenological approaches the value of the symptoms is inserted in the life of the person. For this reason, the work on negative symptoms, basic in the axiological anchoring of the person, becomes highly relevant.