Introduction

More research in recent years has examined the subjective experience of mental illness and psychosis (Davidson et al. 1998; Gee et al. 2003; Roe et al. 2004; Roe and Lachman 2005).

First-time psychotic patients describe the psychotic experience in terms of interference in the perception of the self (Möller and Husby 2000). The patients experienced a painful emotional indifference, a distance to themselves and a frightening feeling of being unreal and of completely having lost themselves. Participants also described how they experienced an extreme preoccupation with their own overvalued ideas, a preoccupation with their inner world and a need to define and analyze everything they were thinking. In another study (Barker et al. 2001) participants described the initial phase of schizophrenic psychosis as a disastrous breach with self-esteem and life-world. Stanghellini and Ballerini (2007) found that patients with schizophrenia are primarily concerned with ontological questions such as what is reality and what is real. This means that phenomenona normally seen as facts are questioned. They further found that persons with this diagnosis experience a loss of common sense and that they feel disconnected from common, shared reality. The patients also saw themselves as radically different from other people.

Gee et al. (2003) found that the psychosis experience of patients with schizophrenia included feelings of withdrawal, tiredness, insomnia, loss of motivation and energy, suspiciousness, hearing voices, as well as paranoia and depression. Hirschfeld et al. (2005) examined young men’s experience of psychosis, and they described that their usual interaction with the outside world changed. Instead of taking events in their daily lives for granted, they experienced themselves in psychosis as suspicious and they described a feeling of insecurity. Furthermore, participants in another study (Walton 2000) described how during an acute psychotic period they saw others as threatening and unpredictable, which resulted in their avoidance of everyday activities.

The sense of control, or rather the loss of control, appears to be an important part of the psychotic experience (Kilkku et al. 2003; Michelle et al. 2007). Michelle et al. (2007) compared the subjective experience of paranoia between persons who sometimes had paranoid feelings without having been diagnosed with mental illness and those diagnosed within the schizophrenia spectrum. Participants in both groups reported having experienced unusual feelings or perceptions. What distinguished the groups was that individuals with schizophrenia spectrum disorder experienced what they saw or heard as being outside themselves and that there were events beyond their control. On the other hand the non-diagnosed subjects experienced that they had control over events. They regarded strange experiences such as illusions they themselves created but did not feel themselves to be controlled by their thoughts and ideas. What is more, the feeling of having control in life seems to be important in recovering from psychosis. Hospital patients diagnosed with psychosis described that the ability to develop strategies to take control of their voice hallucinations and become active agents in their lives was an important part in recovery (Roe et al. 2004).

Although the above mentioned findings are important contributions to the knowledge of the experience of psychosis, we believe that our phenomenological investigation may further enrich the understanding of the psychotic experience. A phenomenological study may help us to capture a holistic meaning structure of this lived phenomenon in question. Thus, our aim is to trace out the meaning structure of the lived experience of psychosis.

Method

Participants

Six subjects participated, two men and four women in the age group 20–40 years. Four participants have been diagnosed with psychosis UNS, one participant has been diagnosed with schizophrenia and one participant has been diagnosed with postpartum psychosis (APA 1994). The group is heterogeneous with regard to psychosis duration, time before they sought and received help, ethnic background and social conditions. Some of the participants have been treated in psychiatric inpatient care; others have only been treated through outpatient care. Participants were selected by psychologists working at an outpatient care center. Our instruction to them was to select participants who were judged to be sufficiently recovered to have some distance to their psychosis. Thus, the only criterion for exclusion of participation was if the psychologists estimated the patients to be too sick to be interviewed. Potential interviewees were contacted first by letter from a psychologist. The letter contained a brief description of the investigation and asked whether the patient’s name and telephone number could be disclosed to the researcher. Those who consented to contact received a second letter with more detailed information. The patients who wished to participate contacted the researcher themselves. This was the most ethical way in which we could recruit participants. Our judgement is that the fact that psychologists at an outpatient care center selected the patients did not have an impact on the results. Neither did we ever experience, during the interviews, that our way of recruiting the participants affected what they told us. Furthermore, we perceived no difference in the character of the interview depending on if it was conducted at the psychiatric outpatient clinic, which was the case for two of the participants, or if the interview took place at the home of the participant, which was the case for four participants.

Ethical Considerations

This study was conducted in accordance with the research ethics principles recommended for the humanities and social sciences in Sweden (Medical Research Council for Research Ethics 2003) and in accordance with the Helsinki Declaration (2008). The interviewees were informed that participation was voluntary and that they had the right to terminate their participation at any time during the process. They were also informed that refusing to participate would not affect the care that they were receiving. For convenience, the time and interview location was scheduled according to the wishes of interview subjects. The interviewer tried to be responsive and attentive throughout the interview to patient distress. The identity of the persons interviewed has made anonymous in all written reports. The interviewees have given their written consent to participate in the study.

Data Collection

Data were collected through qualitative, semi-structured interviews. An interview guide with only a few questions was used. The questions were open, and follow up questions were adapted to the participants’ responses. The interviews began with a general question in which participants were asked to briefly describe themselves, their background and current life situation. The following questions explored participants’ experience of psychosis during the initial phase, the acute phase and until the individual sought or received help. Questions were asked about the first signs that something was wrong or different, what changes they experienced, their own reactions to what happened, and how long it lasted before they realized they needed help. In addition, we explored whether, and if so how, their experience of the outside world and other people changed during psychosis. If the interviewee did not spontaneously mention hallucinatory experiences, the interviewer asked about such experiences. The interviewer deliberately avoided using the words disease or illness and tried instead to capture the participants’ own labels for their experiences. The interviews were recorded digitally with participants’ consent, and each interview lasted between 45 min and about an hour.

Analysis of Data

The analysis of the data used an empirical phenomenological-psychological method (the EPP-method, see Karlsson 1995), the aim of which is to make explicit the meaning structure of the subjects’ concrete descriptions of their experiences. The phenomenological analysis of the subjects’ spontaneous experiences can be described briefly in three points:

  1. (1)

    The phenomenological analysis of consciousness-as-intentionality (e.g., Husserl 1962/1913, 1977/1925) constitutes the starting point for the empirical phenomenological-psychological method (see Karlsson 1992, 1995). Consciousness-as-intentionality divides experience analytically into a subject and an object pole. The subject always relates in a special way to the object. The subject constitutes the object pole, i.e., the subject bestows meaning upon the object (see the following point). The intentionality of consciousness is a general point of departure, in that all descriptions of experience are interpreted in terms of how the subject (person) constitutes the object (“object” should be understood in a broad sense, as object for the acts of consciousness). The constitution of the object, or in other words, how the object is given (shows itself) in and through acts of consciousness is the focus of the analysis. In this study, the focus is on how people experience a psychosis.

  2. (2)

    The phenomenological researcher is interested in the meaning of the persons’ experiences, in light of the phenomenon being studied. The specific facts that the subjects’ concrete descriptions contain, for example the fact that a person started to play indoor bandy is not of interest in itself. The aim is rather to discover (interpret) the meaning that it had for the person to start playing indoor bandy, in this case it was an attempt to try to be “normal”. This second point, the meaning of experience, is intimately bound up with the point above, the intentionality of consciousness. The meaning of something is dependent upon the specific way the subject comports herself/himself to the object.

  3. (3)

    The phenomenological analysis is based upon the experience itself. It is the world of the psychotic from within which is described. One can say that phenomenology partakes of an “inside perspective,” in the sense that one tries to avoid explaining or describing experience with concepts and frames of references falling outside of the experience. A phenomenological analysis seeks to be as faithful as possible to the phenomenon in question. However, it is not a mere phenomenal description. One does not just reiterate experience, but rather attempts to describe the logos of the phenomenon, that is, to specify the necessary constituents (structure) needed for that particular phenomenon to be what it is.

In accordance with the phenomenological approach we have not used any theories or hypotheses in order to find out the meaning structure of psychosis. However, our empirical research is based on phenomenological philosophical insights such as the notion of intentionality mentioned above. No doubt, our understanding of the psychotic experience was much helped by viewing this experience against the background of an intentional normal experience of the world. In other words, phenomenological reflections on the so-called life-world experience helped clarifying the psychotic experience. Let us therefore briefly discuss the normal life-world experience.

The Normal Life-World Experience

The psychotic experience can be understood as a breach with a normal life-world experience, which is why it may be of help to delineate some important characteristics of the normal life-world. Inspired by various phenomenologists’ discussion and characterisation of the life-world, we would like to outline certain characteristics pertinent to our specific aim.

The life-world is the historical, cultural and social conditioned world, into which we are born and grow up, and which we take for granted. Thus, the life-world is an intersubjective world (cf. Zahavi 2001), which among other things imply that I am—from my subjective perspective—able to understand the possibility that other people see the same thing as I do. We have a shared comprehension of the world’s character. We are able to “tone in” and feel what it’s like to be another human being with her/his feelings that is a basis for creating social relations with others.

We can describe, with the help from Heidegger (1980/1927), the primordial way in which we are in the world in terms of a practical, non-reflective and non-theoretical engagement. The objects that we encounter in the world are understood in their function, in their use value (i.e., as equipment). For example, the saucepan is used to boil potatoes in. The equipment points further to an activity. In our example, the saucepan is used for cooking a meal. Furthermore, in one’s concernful dealing with the equipment, it is given in an implicit way and not thematically, that is to say, one is not thinking of the saucepan, but simply use it one’s activity. One’s understanding and knowledge of it is of a “know-how” character. We see here that the piece of equipment (a saucepan) points to or refers to an activity (the cooking). However, the chain of references does not end with one’s work or activity. The activity, in this case the cooking of a meal, does not take place in a vacuum. It points to another reference, namely to a human being, or in Heidegger’s term “Dasein”. The activity serves a purpose, which is carried out to satisfy human desires, wishes and needs. We thus have a chain where a piece of equipment, included in a totality of equipment, points towards an activity, and now we can see that also the activity in turn points to that “for-the-sake-of-which” (to use Heidegger’s expression). In this case the cooking of the meal is done for-the-sake-of satisfy one’s hunger. The chain of references ends with the primary “for-the-sake-of-which” of a human being.

Here, we simply want to highlight in the above description our practical, future oriented and instrumental way of being in the world. These are the three characteristic traits in life-world experiences that we want to preserve, in order to discuss further these characteristics in relation to psychotic experiences. Furthermore, there are some other characteristics in the life-world experience that we would like to shed light on, namely our embodied existence (cf. Merleau-Ponty 1962/1945) and the notion of intentionality (e.g., Husserl 1962/1913, 1977/1925).

The notion of intentionality, which was briefly described under the “Method” section and that we would like to describe somewhat more, entails both an act of consciousness directing towards an object (other than itself) and that it is conscious of itself (self-consciousness). Consciousness-as-intentionality is to be understood in a very broad sense, including perceptual experiences as well as higher forms of intentionality such as voluntary processes (I wish that… I decide that…) or cognitive processes (I judge that… I expect that…). Thus, object intentionality (i.e., consciousness directed towards an object other than itself) is always connected to awareness that it is I who is the agent of constituting consciousness. This awareness does not need to be thematic but is grounded in body intentionality. Thus, we have an intimate and mutual connection between body intentionality and object intentionality. This body intentionality is, in other words, a pre-reflective bodily awareness that accompanies all my experiences of the world and objects in the world. Self-consciousness which belongs to the body-ego is, thus, not a thematic reflection about one-self, and it is important to differentiate between a body-ego’s pre-reflective self-consciousness and a full-fledged ego’s self-consciousness: “…it is necessary to differentiate pre-reflective self-awareness, which is an immediate, implicit, irrelational, non-objectifying, non-conceptual and non-propositional self-acquaintance, from reflective self-awareness, which is an explicit, relational, mediated, conceptual, and objectifying thematization of consciousness” (Zahavi 1999: 33). This pre-reflective self-consciousness is not characterized in terms of object intentionality (the conscious acts’ relating to/constituting of an object), but constitutes a necessary dimension in the subject’s experiencing (in the act itself). The self-awareness of kinesthetic movements and the bodily capacity indicates that the original self-awareness entails an awareness of “I can” (if I, for example, turn my head somewhat, I will get a glimpse of another view of the object). One can say that all experiences are accompanied by an experience of myself being an agent of my experience.

In other words, experience is from the beginning given as one’s own experiencing. In the experiencing there is at the same time an implicit self-consciousness. On the bodily, rudimentary level, it is not a question of an explicit self-consciousness (ego cogito), but about an “anonymous” I-experiencing. In experiencing pain, it is my pain. The experience of pain is not followed by the question; “whose pain?”, but the pain is immediately and directly connected to an experience of the ego. Different psychical means of externalizing the pain outside myself only confirm that it is my pain after all.

Results

The above description of a normal life-world experience can be seen as describing an ontological structure to which we always relate in one way or the other. What is specific about the psychotic experience is its suffering and feeling of estrangement with respect to the normal life-world experience. The results will be presented in the form of five characteristics that constitute the meaning structure in the psychotic experience. These five characteristics are: the feeling of estrangement in relationship to the world; the dissolution of time; the loss of intuitive social knowledge; the alienation of oneself, and finally; the loss of intentionality/loss of agency.

The Feeling of Estrangement in Relationship to the World

The interviewees describe how the notion that what happens in the life-world is razed in psychosis. The world is no longer the safe and familiar place it was. They feel a loss of control, cause vs. effect, why things happen; none of this is clear anymore. They perceive the world as unpredictable.

This interviewee describes how the world feels alien, even though she was in a place where she had been before. Reality is no longer recognizable.

It was at some point, I remember, you could sort of see at night … there is like some kind of large chimney there at the hospital across the road, one you can see from the window … I recognized it because I had lived nearby of just noticed it was the hospital. But I experienced it as if I were somewhere else as well … as if there had been a nuclear war or something … like the end of the world or something.

One interviewee describes that the feeling of losing control makes him experience the world as changed and occult. Earlier familiar objects get a new symbolic meaning, and they take menacing forms and represent a concrete personal threat. For example, during psychosis, he experiences birds as dangerous and attacking, they are intrusive and intimidating, and he must guard himself against them:

I was afraid of birds and thought they wanted to attack me, I thought these kinds of gulls would attack me, it was probably a sign of my illness and this was in summer, not this summer but last summer … this bird thing – that they wanted to attack me – lasted quite a while.

The Dissolution of Time

In psychosis there is dissolution of the temporal synthesizing capability. Here we will consider the dissolution of time with respect to the psychotic person’s inability to get involved in future projects. Since temporality is the deepest level in intentional life this characteristic is salient in other characteristics as well and we will come back to this in the “Discussion” section.

Participants described having no projects for the future while psychotic. Life took place in the here and now. The drive, motivation and willingness to act seemed to disappear, leading to apathy. Several interviewees describe how they dropped out of school, quit their jobs and isolated themselves. The interviewees below describe how they interrupted their future projects and that their existence centred increasingly on the present.

I dropped out of school, I was in adult education then …. I didn’t meet anyone. I more or less shut myself in at home.

I got stuck in details, lost track of time when doing too much of something … I think it is related to isolating oneself … if you don’t have a job, aren’t with friends, well then you lose it … yes, all the variables are sort of knocked out of action.

One interviewee described how his motivation to do things declined, and life became rather meaningless. The future and what to do later was no longer interesting:

… I also gave up a little too, in ways … I quit going to school and … didn’t look for work and … And then there’s this withdrawal too, and despair at times … it becomes a vicious spiral too, if you’re not in contact with others … That is, you’re getting no input … so then it’s pointless to go to school as well… so yeah … so it’s easy to … to live like that … just thinking of the time as the present … and planning ahead … and then of course everything can just fall apart. OK, … so now I am exaggerating, but yeah … it’s kind of like that.

The Loss of Intuitive Social Knowledge

While psychotic the respondents describe that other people’s behavior suddenly becomes difficult to interpret. The individuals seem to have lost what is usually called their “common sense,” and they may have a hard time remembering how they should be and behave with others. Implicit social rules require focused attention and conscious thought. As a consequence the individual feels outside of and not involved in social situations. It becomes difficult to spontaneously throw oneself into a social situation. Instead the social contact is characterized by distance and cognitive calculation on the part of the psychotic subject. The experience of psychosis is characterized by a deep sense of loneliness, involving an experience of not being able to communicate.

The following examples show how an interviewee felt trapped in contemplation about how to act in common social situations where interaction normally takes place without reflection. He perceives himself to be outside the usual social conventions and has trouble remembering how to socialize with others. He has lost an ability to be spontaneous with others.

Often in some sort of social situation where you are not with friends … like in an elevator or … buying food at the store or something like that … I don’t know how to behave correctly.

With other people?

Yes …

or?

Yes, no … it gets a little weird sometimes.

What happens then?

Well, I sometimes forget, I forget how I’m supposed to do some things.

But I don’t know how … if someone’s sitting and reading a newspaper, can I talk with him or not? … OK, if they’re sitting and reading a newspaper, maybe I shouldn’t, as it would be disruptive… I find this is hard and … / … / No … but you also have to have something to talk about too … but it is strange … I lack social skills.

Another interviewee describes a desperate quest for contact with others, yet he is no longer clear how to begin. He has a certain awareness of the wrong way to approach others, but is unable to compensate. He is afraid of making mistakes, afraid to connect the wrong way.

I didn’t approach anyone … no way. Then I just drove around in my car. Then I went home and slept, and I changed my mind when I got there, so to speak …

So you had decided something in advance, but it didn’t turn out as you had thought, or what?

Yes exactly, I didn’t dare make a mistake, because it would be, like, wrong to meet someone by just going up and ringing the doorbell. So I get there and decide … ‘nooo … I don’t fucking dare, I don’t dare do a thing, because I am so damn weird right now.’ I understood, I understood at the end that I was in a terrible shape, so therefore, … nooo, I didn’t dare, so I drove home again. Or went to sleep when / … / so it ended with being alone in my apartment for ten months or thereabout.

It is not only one’s relationship to the other that becomes disturbed in one’s social life, but also one’s perception of the others’ way of relating to oneself is deeply affected in a very negative way. The patients describe that they experience others as having something in common, which the patients do not share. Some describe that the feeling of alienation makes them suspicious and feel that other people cannot be trusted and may be hiding something.

In the following, the patient feels being outside a community where all share a secret about him. He feels they have information about him, they know what’s going on with him, but do not tell.

It was actually at work that I began feeling that they … how to say it … felt dizzy, so then I wanted to know why I felt dizzy. I began to think a lot. I then wanted information right way, yeah …

Did you think that others somehow knew more, more than you knew … or?

Yes … exactly. That they had some information on me that I didn’t, that I didn’t know myself. That all had information on me, so it was a lot of pressure on me then. Just all this pressure on me.

The following illustrates how the interviewees perceive themselves to be persecuted by others during psychosis.

OK, maybe it was me who looked first, and they looked back, and then it became a thing… that there is someone there who is staring at me or persecuting me or so, usually someone from some security service … each and everyone that I had ever heard of.

You thought that they came from them, or what?

Well, it might be … even the Russian Mafia … and Al-Qaeda too was there, and all those other well-known ones … all of them, all, because this was 2003 and it was very much Al-Qaeda and stuff appearing in the media. All of the organizations that I could name, or even those I couldn’t … I could just sit there thinking, ‘Wait a second, these British (agents) are probably safe, but what the hell are they named …?’ like that. So it was the Mossad and the Swedish Security Service and it was like this … ‘So they’re here too … yes, the Russian Mafia, and I do not know who those are … even what’s going on, like ….

This following interviewee thinks he has magical powers and can control or monitor other people. He thinks his actions can affect other people negatively.

You’re also frequently responsible for everyone… that’s really common if something happens… I can be very observant of my surroundings, … so if something then happens because I did something else in a specific way … that [becomes] the reason, If something bad occurs, if someone gets hurt, or the like / … / I’d then imagine other stuff too, that I was somehow evil and could affect others.

The Alienation of Oneself

During a psychotic experience, interviewees reported an altered experience of some internal change; they felt alienated to themselves, even to their own experiences. They didn’t recognise themselves and felt alienated to their own feelings. Sensory input accuracy could no longer be taken for granted. In early stages of psychosis, the memory of an earlier way of being and feeling could sometimes be compared with their current state. However, it was impossible to explain or understand what it was that had changed. The interviewees describe feeling that something was wrong; yet retain a certain self-consciousness to note that something in them was different. They also describe how, in moments of greater clarity, they tried various ways of avoiding going into psychosis. Instead, they tried to be “normal”. Several interviewees describe seeking explanations from other people on what was wrong with them. They hoped that someone would understand and help.

The following illustrates how part of the interviewee’s mind realizes that there is something wrong with her way of thinking and interpreting the world.

But it was like two parts in one, one part was like really … suspicious and … well, would interpret, not take things as they were, but instead analyzed a lot, and … in totally weird directions … On the one hand, I realized ‘this isn’t good, this isn’t healthy, there’s something wrong’ … so I still had some insight at the same time … but it’s so hard too.

This interviewee describes how he tries to talk sense into himself. He tries consciously to break his way of thinking when he feels he is losing contact with reality.

Yes, also that I … well, the existence itself, or reality, was failing somehow, yep … sometimes it did. But that was because I had been thinking too much. I’d tell myself. ‘Hey bud, get a grip.

Another interviewee describes feeling something was about to happen to him, which makes him afraid to completely lose sight of reality. He tries to “normalize” himself, to get himself together by performing certain everyday routines and activities. He understands that he needs to do something to prevent himself from fully entering psychosis.

And then I tried, I understood to, well, try … playing sports and … well try … being normal … because I realized that much. But it was no good, because I think I was just too weird.

You were self-conscious that something was wrong?

Sure, I was a bit scared too, because in the beginning I was just pissed off, but then I got scared too … because, damn it, … now, now I have to do something or else … all hell will break loose, so to speak / … / So when I was sick I actually got myself together, I noticed that when I was sleeping here and … went for walks and things like that, so I thought ‘damn I got to get my act together,’ so I found a sports team and began to play and it actually got better … but unfortunately I quit.

The interviewees describe an inner awareness that something is wrong. They feel different. They cannot put their finger on what it is that is wrong, which makes it almost impossible to communicate with others. This interviewee turns repeatedly to the clinic and asks for help.

…before I was admitted to the hospital, I just felt … there was something really wrong with me, I needed some sort of care … I went to the ER twice for help. I could not go and say ‘I think I’m hallucinating,’ or … ‘I think I’ve got psychosis’. I couldn’t say that. So, yeah … as I said, I didn’t have a clear understanding of the disease either, and that too is pretty … characteristic of psychosis, but it was something, and I was there! I was there, and I was so disappointed somehow of the health care system, the whole system, because I was there twice before, and then again at another hospital.

The ER?

Acute, yes, three times.

What happened when you got there?

Twice, I was there alone, and the third time with my mother and my brother, and I had to tell them to take me to the hospital, I didn’t feel right. … Mom didn’t think it was anything. This was perhaps … two weeks or ten days before … I got sick completely, before the family decided that I had be hospitalized.

The same interviewee describes how she went deeper into psychosis just 1 week after an acute admission. Her realization that there was something wrong with her, her self-consciousness disappears completely.

But once they finally wanted to take me to the hospital, I told them there was nothing wrong with me. Up until then it was me telling them ‘I have to go to the hospital,’ because I still had a little insight left, but it finally went away … So that night, while we were waiting for the taxi, I said to them, ‘but there’s nothing wrong with me. Just to confirm that I’m completely healthy, let’s go to the hospital and get it confirmed that I’m completely well. There’s nothing wrong with me. Just so you can stop worrying. If you really think that I am sick, all right, then we go to the hospital so we get it confirmed by the doctors that there’s no problem with me. It’s all right with me, everything is as it should, I am completely well’. … that’s what I told them, and then we went to … the hospital.

Loss of Intentionality/Loss of Agency

The previous description of the alienated self will here be further developed in terms of the experience of a loss of intentionality in particular with respect to a loss of one’s agency. This disturbed feeling of one’s agency is not restricted to a difficulty in initiating actions, but also comprehends a difficulty in affirming that my experiences and my feelings are MINE. It is as if my experiences and feelings did not belong to me. When it comes to loss of intentionality/loss of agency we include both ego-directed as well as (thematic) body experiences.

One way that this loss of agency comes out is the feeling that one is controlled by someone else, by an external force. Some experienced a compulsion to perform certain acts, a feeling that there was someone else controlling his/her own body. Conversely, the theme of control also includes the feeling that the patients could control other people, that they involuntary can control others’ behavior.

Several interviewees described that they were magically steered by other people. The following respondent feels she is no longer solely responsible for her actions; there is another person who steers her to act in a certain way.

It went so far that, for example, … if I stumbled over something, I thought, oh there’s someone else, there’s someone who wants me to trip and stumble, so then I stumble and think ‘there’s someone controlling me somehow’.

In this above quote we want to pay attention to how the person experiences his body as controlled by others. The body ceases to be a lived (intentional) body and becomes experienced in an objectified way.

Another interviewee described feeling a compulsion to go in a certain pace and to take a pinch of snuff; he no longer feels it is his own will or desire governing his actions. He also senses an unspoken threat that compels him to obey the external governance.

Yeah … sometimes I felt like I needed to walk at … a specific pace, something strange like that and … then suddenly I had to take a pinch of snuff, jam it under my lip and the feeling intense too, really weird, but I don’t get these feelings anymore … I did it back then because I had to or else … and my craving for snuff could be huge sometimes, even though I had just used snuff then. … Weird stuff like that, which I couldn’t explain afterwards … the feelings weren’t related to anything … not like they are now. As if it were someone else who … controlled those feelings I couldn’t control myself. That’s how it felt.

Finally, let us present an example of psychotic experience when the feeling is as if it is not really mine.

I felt that I could not be myself, and it felt as unfair somehow. Because I felt that I was not myself, I was somewhere else or something else had happened, because I mostly just sat still and said practically nothing.

Discussion

Let us first discuss our results with some of the findings in other relevant research. Thereafter we will articulate our contribution to this field of research.

The first theme, the feeling of estrangement in relationship to the world, reflects that the psychotic experience is a clear break from the everyday life-world experience. Sass and Parnas (2003) describe the schizophrenic experience as a loss of the ability to see things in their right perspective. They argue that the implicit sense of what is true or false, probable or not, is lost in psychosis. They further argue that the automatic pre-understanding of how things fit together, what feelings, behaviors and events mean in different contexts, disappears. The world is no longer given as a stable background to what is experienced and no longer taken for granted. Accordingly, several interviewees in the present study described that while psychotic, they lost their common sense, their ability to critically watch their feelings, thoughts and experiences. The loss of common sense pervades all themes in the investigation and appears to be an important part of psychosis.

In the second theme the interviewees described dissolution of time, how they perceive the world in psychosis as centred on the present and temporality seem to be dissolved. They abandon future goals. They described how they left school, work and other everyday routines and instead turn their interest increasingly inwards, to their own thoughts, to their own inner world. In everyday life we normally have various goals and projects we want to implement, which gives us the motivation to go forward. In psychosis, this driving force, the instrumentality of life, seems to be lost. Instead, psychotic individuals tend to become preoccupied with their own internal ideas and issues related to things usually taken for granted (Möller and Husby 2000). According to Möller and Husby (2000), this internal absorption leads to magical thinking with delusions and profound reflections on philosophical and religious themes as a result. Vogeley and Kupke (2007) as well found that the subjective experience of time, a fundamental part of consciousness, may be “disturbed” in psychotic disorders.

The third theme, the loss of intuitive social knowledge, relates to the social dimension of psychosis. The interviewees describe feeling outside the social community while in psychosis. They no longer remember how to behave in everyday situations, become mired in thoughts about how to act, become suspicious of others and felt that others wanted to harm them. The common behavioral repertoire that is intuitively used in everyday life makes it possible to predict human behavior. This means that we usually know what to expect from other people in different social contexts and how to interpret their behavior (Stanghellini 2000; Stanghellini and Ballerini 2002). In psychosis this implicit knowledge seems to disappear. The interviewees describe how they lost intuitive understanding of what was occurring in various social contexts. They also feel that others know something they do not. This corresponds with findings by Hirschfeld et al. (2005) in which participants describe being no longer able to take their ordinary being in the world for granted and that their usual interaction with the world changed while in psychosis. Uhlhaas and Mishara (2007) too found that patients in psychosis lost the ability to know how to behave in different situations, and diminishment in reflexive modes of thought and being present in the world. While psychotic the individual may also experience problems with intersubjectivity, the ability to know how others think and feel (Davidson et al. 1998; Stanghellini and Ballerini 2007). Interaction partners in clinical situations may use different strategies to improve the communicative interplay with these patients (Fatouros-Bergman et al. 2006; Fatouros-Bergman et al. 2010). Blankenburg (1971) writes about the schizophrenic alienation, a sense of standing outside the usual social conventions in which the individual feels socially cut off.

The alienation of oneself was the fourth theme and another essential part of the psychotic experience. The patients described themselves as changed; something is sensed to be wrong, as psychosis is perceptible but impossible to communicate. This corresponds well with results of Möller and Husby (2000) in which participants described how they experienced psychosis as something that felt wrong within, yet that it also was impossible to communicate. They found that altered self-experiences are common in the early stages of psychosis. They found that these altered self-states may last for several months before psychosis manifests overtly. Several studies of the subjective experience of psychosis have also shown that changes in the experience of self constitute a central part of the psychotic experience (Davidson and Stayner 1997; Gee et al. 2003; Hirschfeld et al. 2005; Möller and Husby 2000; Roe and Lachman 2005; Uhlhaas and Mishara 2007). Several of our interviewees made various attempts “normalize themselves” in response to the feeling that something was wrong. This was also found by Sass and Parnas (2003), who describe how psychotic patients are sometimes able to minimize their symptoms through various ways of activating themselves and by distracting their thoughts. This way of dealing with the psychosis may temporarily make the individual feel as usual, however, outwardly normal acts may unnecessary delay the search for help (Möller and Husby 2000). Some interviewees in the present study described how they approached local care providers with their concerns, but failed to get needed help. Möller and Husby (2000) argue that patients’ inability to interpret and communicate their changing experiences of themselves at an early stage of psychosis is a problem in the timely treatment of psychosis.

The interviewees also described a fifth theme, the loss of intentionality/loss of agency. They feel that they have lost control over their own life, over themselves and over their own body. At the same time, paradoxically, they feel that they can control others. Kimura (1992 as ref. in Sass 2001) describes the feeling of loss of control as an experience of alienation from both oneself and one’s feelings and actions. He claims that the alienation may also lead to experiencing one’s own actions and thoughts to be alien and controlled by other people, or by sensing that these may even be someone else’s experiences. Several interviewees in the present study described how the psychosis evoked questioning what was otherwise taken for granted, such as becoming increasingly absorbed by wondering whether what they felt or thought were truly their own. Kircher and Leube (2003) argue that schizophrenic psychoses mainly consist of delusions about control. They describe it as a feeling of not being the “agent” in one’s life anymore, and that the feeling of being master of one’s body and movements becomes lost.

To understand the meaning structure of the psychotic experience we have to consider it as a breach with an ordinary/normal, rational life world experience. In the normal life world experience we move confidently through the world in a spontaneous perceptual-embodied way. The psychotic experience profoundly shakes this normal experience that however still continues to function as the background of the psychotic experience. The psychotic experience is comprehensive and entails an estranged relationship to the world including its object and their interconnectedness with one another, to other human beings, to myself and to my temporal living in the sense that there is an effacement of realizing projects and achieving future goals. One’s existence tends to be reduced to a horrifying here-and-now. One’s embodied being-in-the-world changes from a spontaneous, intuitive and immediate comprehension to a strained cognitive calculated way of being. However, the psychotic breach with the normal life world experience does not amount to a complete loss of it. One is not totally lost in the psychotic world, because if one were there may be no ground for the suffering that accompanies psychosis as well as all other kinds of psychopathology.

We want to emphasize that the psychotic experience entails the whole meaning structure presented here. This meaning structure entails a radical and comprehensive breach with a spontaneous embodied intersubjective world. Even though we consider the psychotic experience to entail the whole meaning structure presented in the Results, we would like to select two fundamental dimensions—our embodiedness and temporality—constitutive of being a human being, both in her normal and pathological (psychotic) way of being in the world.

In the normal life-world experience we have an intentional embodied subject; the body presents itself as a lived body (Leib) and on this level the intersubjectivity poses no problem. As an incarnate being—Merleau-Ponty claims—“the perception of other people and the plurality of consciousnesses no longer present any difficulty” (1962/1945: 351). In line with many phenomenologists the intentional life is already secured on the level of the lived body (Leib). Consequently, we can see that the disturbed psychotic experience takes place on the level of the body. Richir (2004: 341 ff.) discusses how the lived body (Leib) in psychoses tends to become an objectified body (Körper). The embodied intentionality that transcends and opens up towards the world and other co-subjects is in the psychotic experience transformed into objectified entities, a division occurs between something inside and outside, and the spontaneous and “natural” experience of belonging to an intersubjective field ceases.

A word should be said about time and temporality. In line with phenomenological thinking where temporality is the deepest level of intentionality, the dissolution of time is of crucial importance for the psychotic experience and permeates all the characteristics of the meaning structure of psychosis. One example of the dissolution of time is when the psychotic subject is prevented from engaging her/himself in future projects. This incapability of pursuing projects and fulfilling goals also prevents an identity growth of one’s self. Another example of the implication of the dissolution of time is the extremely painful estrangement of the self; the feeling that it is as if someone else is the agent of my experience; my experience is somehow not mine. We will soon come back to this peculiar feeling and discuss one possible way of understanding it within a phenomenological framework.

No doubt, some of the structural elements in the meaning structure of psychosis can be found in other pathological non-psychotic experiences. Let us therefore speculate about what the crucial differences are between the meaning structure of the psychotic experience and the non-psychotic pathological suffering. Firstly, the psychotic experience entails the whole meaning structure, which is not the case in non-psychotic pathological suffering. Secondly, the intensity of the psychotic experience is much stronger compared to for example neurotic suffering. For example, the strangeness of the world in psychosis is much stronger both in its horrifying and magic quality compared to other psychopathological suffering. Thirdly, to try to give a more qualitative description of this second point (the intensity of the psychotic experience/suffering) we want to shed light on the ego. The ego’s synthesizing capability is significantly reduced when it comes to psychotic experiences. This lack of a synthesizing capacity pertains to the world, other people, myself and my projects. The ego is in other words seriously limited in its capacity to constitute a harmonious synthesis of acts which is required for there to be enduring and stable objects (of whatever kind it may be).

To deepen the understanding of this limited synthesizing capacity of the ego we would like to introduce the notion of self-consciousness by making a difference between a transcendental and a psychological/empirical ego. We believe that this division between a transcendental and a psychological ego is required in order to account for the suffering person’s awareness that something is in a way not as it ‘should’ be. The difference between the transcendental and the psychological/empirical ego may also be conceptualized as a difference between an ontological and a psychological level. The difference between these two levels become apparent, for example, in states of depersonalization, when a person has the experience of being invaded by others’ thoughts. This experience does not refute the ontologically indisputable fact that it is still I who thinks or experiences these strange thoughts. These depersonalized states always need to be qualified in that it feels ‘as if’ somebody else is thinking in me. In the Results found in this study one can see many examples of this as-if character in the psychotic experience, for example; “I experienced it as if I were somewhere else… as if there had been nuclear war or something… like the end of the world or something,” “As if it were someone else who… controlled those feelings I couldn’t control myself. That’s how it felt”.

Karlsson (2010) discusses psychopathological suffering as being characterized by a lack of an affirmative potentiality of self-consciousness. His discussion concerns psychopathological suffering in general but it may be interesting to include it here since it shed light on a very painful and important trait in the psychotic suffering. Karlsson’s aim is to describe the role of self-consciousness in psychopathology from a phenomenological first-person perspective. Self-consciousness plays an overall psychic function in that there is awareness “that something is in a way not as it ‘should’ be” (186). There is awareness in the first-person perspective to ‘realize’ one’s own distortion and incapacity to constitutionally harmonize an intersubjective reality. Such a capability of self-consciousness to ‘realize’ one’s own distortion should not be understood as if one in one’s wholeness certainly is incapable of explicitly embracing the truth, but as if truth in one way or another were stored within consciousness/self-consciousness. It is rather a dormant and potential awareness—originating from self-consciousness—in the sense that one (the subject) is about to carry out something irrationally and distortedly. This awareness is given from within—that the stream of acts of consciousness is not harmoniously synthesizing. Thus, it is not a question of being aware of what there actually is, but rather of what there is not. To conclude, we would like to suggest that from a phenomenological first-person perspective psychotic suffering entails a seriously reduced capability of (the psychological) ego to affirming subjective and objective existence (and speaking from a first-person perspective one must note that to affirm existence corresponds to an ego’s synthesizing capability).

Validity and Generalizability

The present study is anchored within a phenomenological theoretical framework, stressing the validity of intentionality for being faithful to human nature. The phenomenological clarification of the normal life-world experience was helpful in capturing the meaning structure of psychotic experiences. In using the EPP-method and thereby abstaining from the use of constructed theories to try to explain the phenomenon in question, the phenomenological credo to be as open and presuppositionless as possible was adhered to.

In qualitative research, it is essential that the interpretations form a logical, non-contradictory whole so that they validate each other (Kvale 1997: 215). In this way, plausibility of each interpretation is considered based on how well it fits into a meaningful whole. Interpretations should also be defended by a logical argument structure (Karlsson 1995; Kvale 1997). The results are illustrated by various quotations from the interviews, which provide readers an opportunity to form an opinion on the validity of interpretation. That the reports are retrospective, concerning the time when the interviewees were psychotic, must also be considered. However, this is unlikely to negatively impact the narratives’ validity. In one survey (Cutting and Dunne 1989), despite the considerable time since psychosis, participants were able to report their experiences of psychosis in detail and how it affected them. Our interview subjects’ different gender, age and background provide different perspectives on the subjective experience of psychosis and are considered a strength.

Conclusion

The different structural elements entailed in the presented meaning structure are, generally speaking, in line with the previous research on subjective experiences of psychosis. However, as we have emphasized one has to take into account the whole presented meaning structure, understood as a gestalt, presented here in order to capture the experience of psychosis. The subjects in the present study clearly describe an altered perception of both the self and the world as an essential part of the psychotic experience. They described themselves as changed; psychosis was perceived as something wrong, yet hard to communicate. The normal life-world experience was altered and reality seemed strange. Temporality disappeared. The experience was focused only to the present. The subjects described loss of intentionality, they were no longer agents in their actions but steered by others. The patients also describe problems regarding their ability to socialize and communicate with others. They seem to loose their intuitive social capacity and are prone to suspiciousness.