Volume 16, No 2, Fall 2021 ISSN 1932-1066

Autonomy, Agency, and Schizophrenia

Reflections on Selfhood and Alterity

Louis A. Sass

Rutgers University

Abstract: It is commonly observed that schizophrenia is characterized by diminished capacity for autonomy or self-control, by loss of the sense of being the agent of one's actions or even the possessor of one's own experiences. This feature is emphasized in both Giovanni Stanghellini's book Lost in Dialogue and David Shapiro's book Dynamics of Character. Here I consider some ways in which schizophrenia—an eminently paradoxical condition—can also involve forms of exaggerated autonomy. I argue that schizophrenia is best conceived as involving a diminishment of the normal equilibrium between agency and passivity, between independence and dependence on what lies beyond one's self.

Keywords: Stanghellini, Giovanni; Shapiro, David; schizophrenia; alterity; selfhood; otherness; ipseity; agency; volition; autonomy.


In his erudite and broad-ranging book, Lost in Dialogue, Giovanni Stanghellini offers a bracing overview of psychopathology and, more generally, of many of life's dilemmas by focusing on the issues of dialogue and alterity.1 As Stanghellini shows, both these concepts can have many meanings and many ramifications. Dialogue can be external or internal, interpersonal or intra-personal. The alterity to which one relates may involve other human beings or may involve aspects of oneself that are "other" in the sense of being outside one's volitional control. A major mode of dialogue involves the relationship between the voluntary and the involuntary. Here I would like to focus on this aspect—on "the entanglement between selfhood and alterity, the voluntary and the involuntary" (LD 1)—and to do so in the context of schizophrenia, a topic to which Stanghellini devotes a chapter in this book.

I will take mild issue with something that Stanghellini says in this book (perhaps mostly in passing—it is hardly the core of his argument). This concerns the question of volition, autonomy, or agency in schizophrenia, and thus the nature of the peculiar dialogue—or perhaps one should say non-dialogue—that such individuals can sometimes have with alterity. Even by saying that my disagreement is mild might already exaggerate the difference. As you will see, many of the examples I will use come directly from Stanghellini's own earlier work; and the conclusions I will reach are, I believe, fully in conformity with the core position he espouses in Lost in Dialogue—in particular, regarding Stanghellini's vision of a normal "dialogue with alterity" as one in which the voluntary is in touch with the involuntary, selfhood with otherness.

A Paradoxical Condition

Stanghellini characterizes the alienation characteristic of schizophrenia as involving, above all, "loss of agency and myness" (LD 156). He writes:

Morbid objectivation and externalization of parts of one's body or self, imposed thoughts and drives, and imperative voices are typical examples of schizophrenic phenomena in which the sense of being the author of one's actions and the owner of one's mental processes and contents is jeopardized. [LD 156]

His presentation implies not only that these experiences are characteristic of schizophrenia—which is certainly true—but that they somehow capture the essence or perhaps the trouble genérateur of the illness:

Schizophrenia and melancholia represent two opposite polarities of distorted agency and of responsibility. In the former, the person, while performing a given action, does not feel that he is the one who is voluntarily acting. He feels that the source of his actions is external to him. [LD 156]

This, in fact, is a common view about schizophrenia. For example, David Shapiro sees loss of volition and agency as particularly extreme in schizophrenia, and speaks of a "reversion to prevolitional modes" that is "radical" and "severe."2 Shapiro cites classic authors (Kurt Goldstein, Andras Angyal, Eugen Bleuler, Emil Kraepelin, C. G. Jung) who spoke of

impairment of volition, will or intentionality, or...a condition of extreme passivity [involving] inability, or initiate a course of action, to make a considered choice, or even to concentrate, to focus or shift attention at will. [DC 128]

No one would deny, of course, that persons with schizophrenia do indeed often demonstrate a diminished degree of normal autonomy or agency—provided that this description refers to the exercise of standard forms of action and thought that are directed toward the achievement of conventional purposes within the standard social order.

A point that is neglected however—by Shapiro and others, and, it seems to me, also by Stanghellini in Lost in Dialogue—I have addressed in an earlier paper:

while persons with schizophrenia certainly do manifest very pronounced diminishments of agency or autonomy, in terms both of experience and action, they may also, at times, experience heightened forms of personal agency, or may think and act in ways that suggest exaggerated autonomy—at least according to a number of the standard meanings of "autonomy."3

As Henry Maudsley once noted, those who

have practical experience of the insane know well what a power of self-control they sometimes evince when they have sufficient motive to exercise it.4

This duality may be difficult to conceptualize or to explain. It is however very much in keeping with the generally paradoxical nature of this illness or set of illnesses, which so often seems to defy normal or common-sense forms of psychological understanding or explanation.

An adequate understanding of schizophrenic psychopathology requires one to appreciate not only the surprisingly antithetical nature of many schizophrenia symptoms, but also a point that Stangehellini emphasizes in Lost in Dialogue, namely, the way in which, in normal experience, such opposite characteristics as autonomy and dependence, or agency and passivity, may, in fact, typically coexist in various forms of complex complementarity.

Exaggerated Autonomy

One must begin by acknowledging that many characteristic symptoms and signs of schizophrenia do indeed indicate a striking diminishment of agency or autonomy that is, in Shapiro's words, "distinctively schizophrenic" (DC 130). Perhaps the most obvious examples are the well-known "first-rank symptoms" or "positive symptoms" that Kurt Schneider had introduced into the nomenclature of schizophrenia. For instance, Angyal describes how in schizophrenia patients the distinction between self and external world is severely impaired, as shown in one patient who said that, when eating, he had the feeling "that another tongue comes and takes the food."5 Clearly, this patient had lost the normal sense of being the owner and agent of his own bodily action. The so-called "negative symptoms" and "disorganization symptoms" provide further examples. In the book Varieties of Psychopathological Experiences,6 Carney Landis mentions a study published in 1913 that details the case history of one of Antonín Heveroch's patients with abulia, a 44-year-old businessman who complained of being "without energy or will" and who states:

I don't perceive my will and do everything mechanically...I, myself, can't bring the sensation of will, that is the sensation of the expression of the will to the level of consciousness.7

Before one accepts this as a sine qua non or essential defining or core feature of schizophrenic psychopathology, it is important to recognize that there are, in fact, other symptoms or features, that are also very typical of schizophrenia, that might seem to indicate just the opposite tendency. This point has been made by various writers on the topic, and that includes Stanghellini himself who wrote some important earlier papers on just this issue.

Many schizophrenia patients, slightly more than half in a sample studied by Stanghellini and Mario Rossi Monti,8 will report a combination of passivity experiences (thoughts, body, or will being controlled from without) together with experiences of abnormal degrees of activity or control—such as the sense of being able to transmit one's thoughts directly to others at will, to tune in intentionally to others' thoughts, or to exert intentional mental control over objects and events in the outside world. "I felt very strong and I thought I was a wizard" (BD 166), said one such patient regarding his ability to transmit thoughts to other people. This suggests that at least an experience of exaggerated autonomy or agency is, in fact, quite common in schizophrenia. An exaggerated sense of volition and autonomy can also be prominent at the level of values, as Stanghellini has also shown.

In a study of transcripts of therapy sessions, Stanghellini and Massimo Ballerini found that patients with schizophrenia or schizotypal disorder were extremely likely to endorse the related values of independence and idiosyncrasy, and to disdain dependence and conformity.9 Stanghellini and Ballerini speak in this context of idionomia and antagonomia. The first designation refers to a patient's sense of "radical uniqueness and exceptionality of one's being" (VPS 131); it is often being felt as a gift involving a mission or a superior, metaphysical understanding of the world. The second designation refers to the will to adopt an eccentric stance against shared assumptions and other people. Clearly, these designations involve what, for example, Charles Taylor describes as "strong evaluations,"10 and Harry Frankfurt calls "second-order desires" and "second-order volitions,"11 for they imply not so much any specific judgment or evaluation, but rather a kind of overall, meta-attitude toward the kinds of attitudes, evaluations, or actions one ought to adopt. To engage in strong evaluation is not just to evaluate, to judge given objectives or ends as good or bad. It is to have an attitude about one's own evaluations and thus toward the overall sort of person one wishes to be. Both Frankfurt and Taylor view this level as indispensable for what it is to have free will or to be a person.

The insistence on autonomy is very apparent in the patient statements listed by Stanghellini and Ballerini in the section "Refusal of Interpersonal Bonds":

Interpersonal bonds have no reason to exist.

I reject my tendency towards identifying myself with what the others say.

What I detest more than anything else is being persuaded by others.

I would like to be clear-headed to have intuitions. And for this I would like not to be too domesticated.

I've always liked being different very much.

I'm getting to be more humane. Will it ruin my brain? All this humanity is upsetting my own special framework. It's polluting me. [VPS 137]

In the section "Refusal of Common Sense Knowledge and Semantics" the authors list patient statements that demonstrate that such refusal may lead persons with schizophrenia to prefer alternative modes of knowledge:

My aversion to common sense is stronger than my instinct to survive.

Revelation is a subjective vision of the human condition disconnected from the "common" idea to be or to belong to the human condition.

Madness is necessary to human intelligence to get to the higher levels. [VPS 138]

This refusal may also inspire persons with schizophrenia to act in non-conventional or contrarian ways as it is evidenced, for instance, by one patient's remark:

People buy a ticket to get on a train—that is the rule. But this rule is for them, not for me. [VPS 138]

A further example is the case of Philip, a young man with schizophrenia whom the author knew well, who would dance for hours while balancing on one foot, to the end of developing his own, unique art form. In a letter, Philip declared his strong evaluation of independence and autonomy, writing that he refused to be limited by "ideas of a normal metabolism."12 He adds:

the importance of Reality is merely a social sanction (society inevitably ruled by those involved in reality). [MM 110]

In a personal letter quoted by psychiatrist Manfred Bleuler, a patient wrote:

I'm enjoying so much wonderful freedom in my mental illness...The life of a mental patient means being a prince, with all its freedoms and thoughts.13

There is, of course, something bizarre, some might even say insane, about these attitudes or projects mentioned above; one might use one psychiatrist's phrase and describe these attitudes as "pathological freedom."14 Such persons could certainly be described as lacking in standard autonomy. But the sheer bizarreness or idiosyncrasy of their behavior or their existential project should not be allowed to obscure the fact that what accounts, in these cases, for the diminishment of normal autonomy, is largely the heightening of other forms of autonomy—namely, hyperbolic exaggeration of independence and rejection of convention. This heightening is not only perfectly real, in the sense of being expressed in actual activity (actual bodily movements, ways of speaking, peculiar inventions, and so on). It also conforms to the second-order commitments of the individual (for example, to Philip's rejection of "Reality [as a] social sanction"—mentioned above) and thereby fulfilling the aforementioned criteria for the definition of free will and personhood as introduced by Taylor and Frankfurt. Some of these individuals seem, in fact, to be clear examples of the type described in an autobiographical short story by the writer Robert Walser, who himself was an individual in the schizophrenia spectrum. These individuals would live by Walser's dictum that "one should always be bowing inwardly to the pure image of freedom"15 and would recognize themselves as being a "connoisseur and gourmet of freedom" (EF 181).

There seem, then, to be various ways in which the self—and indeed the most basic or fundamental form of selfhood, which is the sense of existing as a subject of experience and agent of action—can be altered in schizophrenia. It is not always and only a matter of a diminished sense of self, but may also involve exaggeration. Sometimes these two, seemingly antithetical tendencies may even co-occur in rather paradoxical ways, for instance, when a patient who claims to be omnipotent or all-knowing will also claim not to exist or that his own thoughts and perceptions are under some kind of alien control (MM 270).

Some persons with schizophrenia (or schizoid personality) may, in fact, have a sense of superiority over what they may perceive to be the bovine or mechanical condition of normal individuals, who seem so completely unaware of, and subservient to, the rituals and routines they are indeed following. Another patient, Lawrence, for instance, claimed that the great majority of human beings were not truly living minds but only "organic machines" or "mental vegetables" who lacked a real soul. He claimed that

what appeared to be thinking on the part of such individuals was, in fact, only the mechanical retrieval and processing of facts and memories from a memory bank. [MM 277]

Such attitudes and associated forms of awareness may have some roots in genetic, neurobiological, or developmental factors. They are not, however, merely passively registered. Indeed, they often give rise to a mode of life in which the person actively attempts to stay independent of grounding conventions, thus manifesting the kind of active or agentic attitude—or Stellungnahme, as Jaspers describes the process where the patient reflecting on his anomalous and disturbing experiences, "can see himself, judge himself, and mould himself"16—a process that Stanghellini aptly describes as playing

an active role in interacting with [the] aberrant experience that derive from [the patient's] basic vulnerability. [LD 150]

In this sense a person not only assents to but commits oneself to a mode of life to which one may, in some sense, also be doomed. Here, one might say, it is more apt to speak of a schizophrenic person than of a person with schizophrenia, given that the former phrase may better capture the ways in which there is an active commitment to, and not just a succumbing, to what might be considered a schizophrenic form of living.

It is perhaps most accurate to speak here of a quasi-choice of an entire existential stance. One might ask, however, how different this situation of quasi-choice is from that of the normal individual. The normal person does, after all, also acquiesce to a mode of functioning (in this case, however, a practical and conventional mode, imbued with common sense) that he does not so much choose as inherit.

A Healthy Dialogue with Alterity

It is misleading to characterize schizophrenia simply as a condition of diminished agency or autonomy. Rather more accurate it is to say that the condition involves a diminishment of the normal equilibrium between agency and passivity, between autonomy and heteronomy—or between independence and dependence on that which lies beyond the self. The normal or standard kind of equilibrium is well captured in these lines by Maurice Merleau-Ponty:

The choice which we make of our life is always based on a certain givenness. My freedom can draw life away from its spontaneous course, but only by a series of unobtrusive deflections which necessitate first of all following its course—not by any absolute creation.17

Many of the forms of exaggerated autonomy found in schizophrenia seem to involve a denial of this founding complementarity of autonomy and heteronomy—it is as if such a patient believed, against all reason and experience, that he or she at least might be able to transcend all dependence on other human beings or on surrounding traditions, cultural forms, or even material realities. What one should emphasize, perhaps, is the loss or refusal, not of agency, but rather, of that inextricable mix of freedom and constraint, of agency and obstacle, of activity and passivity, that defines the fabric of a more standard relationship to social and objective reality. And here I agree with Stanghellini when he speaks of a healthy "dialogue with alterity" (LD 22-7) or "sense of agency and responsibility" as one in which "the voluntary is in touch with the involuntary, selfhood with otherness" (LD 160).

1 Giovanni Stanghellini, Lost in Dialogue: Anthropology, Psychopathology, and Care, Oxford, UK: Oxford University Press, 2017. [Henceforth cited as LD]

2 David Shapiro, Dynamics of Character: Self-Regulation in Psychopathology, New York, NY: Basic Books 2000, p. 128. [Henceforth cited as DC]

3 Louis A. Sass, "Autonomy and Schizophrenia: Reflections on an Ideal," in Personality and Psychopathology: Critical Dialogues with David Shapiro, ed. Craig Piers, New York, NY: Springer 2011, pp. 99-131, here p. 101.

4 Henry Maudsley, "Insanity and its Treatment," The Journal of Mental Science XVII/79 (October 1871), 311-334, here p. 322.

5 Andras Angyal, "The Experience of the Body-Self in Schizophrenia," Archives of Neurology and Psychiatry 35/5 (May 1936), 1029-1053, here p. 1036. [Cited in DC 118]

6 Carney Landis, Varieties of Psychopathological Experience, Secaucus, NJ: Holt, Rinehart and Winston, 1964. [Henceforth cited as VPE]

7 Antonín Heveroch, "Über die Störungen des Ichtums." Zeitschrift für die gesamte Neurologie und Psychiatrie 19/1 (December 1913), 422-496, here p. 427, transl. Carney Landis (VPE 347).

8 Giovanni Stanghellini and Mario Rossi Monti, "Influencing and Being Influenced: The Other Side of 'Bizarre Delusions,' 2. Clinical Investigation," Psychopathology 26/3-4 (1993), 165-169. [Henceforth cited as BD]

9 Giovanni Stanghellini and Massimo Ballerini, "Values in Persons With Schizophrenia," Schizophrenia Bulletin 33/1 (January 2007), 131–141, here p. 138. [Henceforth cited as VPS]

10 Charles Taylor, "Responsibility for Self," in The Identities of Persons, ed. Amélie Oksenberg Rorty, Berkeley, CA: University of California Press 1976, pp. 281-299.

11 Harry G. Frankfurt, "Freedom of the Will and the Concept of a Person," The Journal of Philosophy 68/1 (14 January 1971) 5-20.

12 Louis A. Sass, Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought, Oxford, UK: Oxford University Press 2017, p. 110. [Henceforth cited as MM]

13 Manfred Bleuler, The Schizophrenic Disorders: Long-term Patient and Family Studies, transl. Siegfried M. Clemens, New Haven, CT: Yale University Press 1978, p. 490.

14 Carl Schneider, "Beiträge zur Lehre von der Schizophrenie, III. Mitteilung, Über die Unterschiede zwischen schizophrener Sprache und Aphasie und zur Theorie der schizophrenen Sprachstörungen," Zeitschrift für die gesamte Neurologie und Psychiatrie 96/1 (Dezember 1925), 251-274, here p. 251.

15 Robert Walser, "Essay on Freedom," in Selected Stories, transl. Christopher Middleton, New York, NY: Farrar, Straus and Giroux 1982, pp. 179-81, here p.179. [Henceforth cited as EF]

16 Karl Jaspers, General Psychopathology, transl. J. Hoenig and Marian W. Hamilton, Chicago, IL: University of Chicago Press 1963, p. 424.

17 Maurice Merleau-Ponty, Phenomenology of Perception, transl. Colin Smith, London, UK: Routledge and Kegan Paul 1962, p. 455.