This thesis encompasses the first empirical-phenomenological study of the fundamental yet overlooked phenomenon of double bookkeeping in schizophrenia. Briefly put, double bookkeeping refers to the sentiment of living simultaneously in two incommensurable dimensions of reality, namely, a common everyday reality, shared with others and a private sometimes psychotic reality, transcending the constrains of the former. The thesis combines phenomenological inspired qualitative interviews with 25 individuals suffering from schizophrenia spectrum disorder (SSD) on the one hand and critical engagement with philosophical concepts on the other. It is an explorative study targeting double bookkeeping as experienced from the subjective perspectives of individuals suffering from schizophrenia. Furthermore, it aims to investigate philosophical issues emerging from this exploration.
Although completely neglected in current mainstream psychiatry, double bookkeeping has been re-discovered in phenomenological psychopathology and philosophical discussions of the (doxastic) nature of delusional belief. These studies deal mainly with theoretical issues regarding delusions.
In line with the phenomenological approach, the thesis argues that double bookkeeping is not simply a matter of holding contradictory beliefs, but rather reflects a global alteration of the relation to reality. From a phenomenological perspective, the two worlds can exist side by side without conflicting because the evidence pertaining to psychosis is not rooted in the evidence of the everyday world, shared with others. In other words, the two realities are not
simply different but cannot be judged by the same standard.
The thesis argues that double bookkeeping is a more comprehensive phenomena pertaining to the core of the mode and onset of psychosis. Double bookkeeping plays across multiple psychotic symptoms and is furthermore at stake in pre-onset phases as well as schizotypal disorder (i.e., a non or pre-psychotic part of the schizophrenia spectrum). The thesis aims to identify the shared phenomenological pattern pertaining to diverse clinical manifestations such as delusions, hallucinations, insight into illness, and Anderssein (i.e., a
sense of being profoundly different). The PhD thesis is built around four papers. The papers are consecutive in the sense that the first paper presents key conceptual and clinical work that guided the empirical investigations presented in the second and third paper. The fourth paper presents a conceptual and philosophical discussion drawing on insights from the first three papers.
In the first paper we propose to identify the shared phenomenological pattern as an instability in the affective articulation of subjectivity. This is an expression of a Gestalt leaving a trace of specificity on diverse and heterogenous clinical manifestations. More precisely, there is a specific form of alterity within the immanence of subjectivity at stake in schizophrenia that involves a sense of a breakthrough to another ontological dimension.
The second paper presents the empirical-phenomenological study addressing double bookkeeping. The most important results are that most research participants experienced to be in contact with another incommensurable dimension of reality considered as being more profound or true. Psychotic experience concerns this different reality, which the patients typically kept separated from the everyday shared reality. None of the patients considered their condition as an illness analogous to a somatic illness. Many of the participants reported that psychotic experiences were nearly impossible to express in common language because they felt radically different from ordinary experience.
Through the phenomenon of Anderssein, the third paper looks specifically into the emergence and development of double bookkeeping. Anderssein is an important concept, and although it has been mentioned in phenomenological-psychopathological research as an aspect of the core disturbance of schizophrenia, it has rarely been thematized in the literature. Most patients described experiencing an elusive sense of doubleness as preceding the development of a more overt sense of existing in two different dimensions of reality. This emergence of doubleness was associated with a feeling of being profoundly and almost ineffably different from one’s peers. This was often articulated as a sense of living outside or in another place than the reality, shared with others. Intersubjective reality appeared increasingly artificial or unreal. We argue that the emerging psychosis is a gradual development and extension of these preceding alterations of existential and intersubjective dispositions.
The fourth paper treats philosophical and conceptual issues that emerged from insights from the first three papers. Particularly, if psychosis pertains to a different ontological dimension and as such is not integrated into intersubjective reality, would such an understanding of psychosis rely on the simple juxtaposition that the thesis sets out to move beyond? Through engagement with the philosophies of Merleau-Ponty and Heidegger, I argue that double bookkeeping can be conceived as expressive of ambiguity and a redoubling of
(constitutive) alienation. Rather than understanding psychotic reality as an opposition to an ordinary shared reality, I argue that global transformation of the structures of (inter)subjectivity pertaining to the dynamic relation to otherness is at stake in schizophrenia. This permits an understanding of double bookkeeping as a rupture within reality, that is, a redoubling of the contradictory and paradoxical nature of reality, rather than an occurrence of two realities.
The implications of a phenomenological-empirical account of double bookkeeping is three-fold: (1) to arrive at a better understanding of the fundamental nature of psychosis and its emergence in schizophrenia; (2) to provide clinicians with a description of this phenomenon in a graspable manner and thus improve treatment and minimize the risk of treatment noncompliance; (3) to conduct more adequate psychotherapy, focusing on helping patients
finding anchoring in the shared world, rather than merely focusing on elimination of psychotic symptoms.