Leaving Psychiatry Chapter 9; Sanity.
On Agreeing to Disagree, Deconstructing Insanity.
“What would have happened if they [new methods of physical and chemical psychiatric treatments] had been available for the last five hundred years?... John Wesley who had years of depressive torment before accepting the idea of salvation by faith rather than good works, might have avoided this, and simply gone back to help his father as curate of Epworth following treatment. Wilberforce, too, might have gone back to being a man about town, and avoided his long fight to abolish slavery and his addiction to laudanum. Loyola and St Francis might also have continued with their military careers. Perhaps, even earlier, Jesus Christ might simply have returned to his carpentry following the use of modern [psychiatric] treatments”
William Sargent (social engineer and one time doyen of British Psychiatry)
"All are lunatics, but he who can analyze his delusions is called a philosopher.”
Ambrose Bierce
Sometime in 2019. Leaving Psychiatry Chapter 9; Sanity.
On Agreeing to Disagree
Whatever science is, is debatable. However, in what is arguably the world’s most prestigious and aptly, if unimaginatively titled, scientific journal, “Science”, its January 1973 issue published what was arguably more investigative journalism than science. I commend you all to read and read again “On Being Sane in Insane Places”. The cast were 8 in number, including the articles author himself, Professor of Psychology David Rosenhan. Each presented to various psychiatric admissions departments, from east to west coast of the USA. Identities were disguised (except at some level for Rosenhan, informing the hospital executive who ostensibly kept the matter secret from the treating staff). They all reported suffering from an auditory hallucination, hearing a voice say enigmatic simple words, “dull”, thud”, “empty”. They also all reported a non-descript sense of existential disquiet, what Jaspers at a stretch might have considered a primary delusion. Apart from these two features of putative psychopathology, in every other way they behaved normally. Yet every one of them was diagnosed with a serious mental illness. All were hospitalized. All were medicated with powerful major tranquilizers (aka “antipsychotics”), or at least they were handed medication. Most of the time they succeeded in surreptitiously pocketing it to flush down the toilet later.
Several conclusions of this study were obvious, chiefly that psychiatrists cannot distinguish the real from the fake. That or worse still, that they didn’t really care what was real or fake and simply responded to appearances of the real for other motives. From this we might be tempted to question what is, or if there is, real psychosis to begin with. Or to put another way, all diagnosis in psychiatry can be said to be couched on an implicit act of faith in one’s fellow man to be as they say they are. Additionally, the study demonstrated the irresistible pull of diagnosis. Psychiatrists simply cannot live without it. They lose all moorings without the labels they ascribe to people, and a history of the silliness of psychiatric taxonomy is not far from being equivalent to the history of psychiatry in toto. The psychiatrist who reads Rosenhan’s paper only to think “but I would not have admitted/diagnosed/medicated” fails to grasp the deeper epistemological game at play.
Apart from the devastating core finding, several more observations or conclusions can be drawn, some of which I observe to persist across time and space in my own career.
Firstly, American psychiatry may not have needed the DSM to achieve inter-rater reliability (i.e. consistency in agreement between different diagnosticians as to the diagnosis in like kinds of presentations). As stated, all patients were diagnosed with mental illness. Seven of eight of the patients were diagnosed on admission with “schizophrenia”, these same seven being diagnosed with “schizophrenia in remission” on discharge. Rosenhan’s study illustrates that prior to the codified nosology of DSM III, psychiatrists were perhaps more reliable than they are now. Yet high reliability (i.e. consistency and uniformity) means not much. The problem is they were all reliably wrong at the outset, and reliably too arrogant to simply revise their diagnosis to confessing they got it wrong. The most reliable of diagnosticians are those who practice the zodiac. Just tell the astrologer your date of birth. You receive your answer. The rest is easy, with 99% of astrologers agreeing on your diagnosis. And so what?
Secondly, were these same patients to live in an age with rapid electronic communication and integrated hospital databases, they would be on record as having a history of schizophrenia. Big brother has a very long memory, and any future unusual behaviour would be stained by past interpretations. The next admission may well be longer still. Sure a patient can be in remission from an illness, but remission is not synonymous with cure. It should not be lost on the reader that this forever binds the patient to psychiatry even when they walk out beyond the threshold of the hospital gate. On re-entry more would be done the second time around, possibly a longer acting injectable antipsychotic (though this was not available in the early 70’s) or a longer course of treatment, especially were it to be discovered they threw the pills in the loo. This history would be recorded as evidence of “lack of insight” and “non-compliance” with oral agents. Schizophrenia is one of many diagnoses that is for life, a stain that can never be washed away. The only cure is a complete revision of history for the patient him/herself, or better yet for the whole of psychiatry. Rosenhan himself chillingly writes “eventually, the patient himself accepts the diagnosis, with all the surplus meanings and expectations, and behaves accordingly”. Or as every good torturer knows, they all break eventually.
Thirdly, the average length of (involuntary) stay in the experiment was 19 days. Putting aside the moral aspect of this extended deprivation of liberty (more than some criminals face in the penal system for serious offences) and putting aside the cost of the medications that pollute whatever ecology the sewer pipes drain into, the real cost of the study in today’s dollar terms was enormous. (Average 19 days per pseudo-patient X 8 pseudo-patients X at least $1000 per day is >$150,000). In more litigious times these hospitals or the state might be tempted to sue. I suspect they didn’t on account of the publicity that would have surely resulted. Revealing weaknesses in the psychiatric art was the greater liability.
Fourthly, “real” patients often detected that the pseudo-patient was a fake, though this was not the case with staff. Moreover, Rosenhan himself observed that most of the time the allegedly authentically insane co-patients appeared as normal as him to himself.
Fifth, Rosenhan’s pseudo-patients semi-quantified the numbers or time of encounters between staff and patient. He writes “those with the most power have the least to do with patients, and those with the least power are most involved with them”. I’ve observed this myself. Psychiatrists will in the abstract say they like and wish to help people (don’t we all say these things?). In private practice they do just that, as a person seen is money earned (and from more of the former flows more of the latter, as with any small business). But my observation is that most psychiatrists, however much they may say they like people, don’t like that subspecies of person we might call the patient. In public practice it is not unusual for those higher up the totem pole to delegate to the juniors the time spent with people, under the self-serving guise of granting the junior doctor the experience they need. The junior doctor will see perhaps at least five patients per day for every one or two the consultant sees, the remainder of the day the psychiatrist talking about the patients and pottering around the endless pathological proliferation of paperwork that keeps most the hospital machine spinning. Most public system psychiatrists are happier as managers than clinicians and suffer no unhappiness if they go the whole day without seeing a patient (though any with any sanity themselves hate management too). As Rosenhan observed, psychiatrists often had the time to engage in more than the bare minimum with the patient. They simply chose not to.
Sixth, though it would seem the hospital staff were duped, the pseudo-patient subjects/malingerers themselves were duped in perhaps a much more pervasive and embarrassing way. These pseudo-patients are said to have been unanimously surprised to the point of shock it was so easy, almost certain before the fact that the psychiatrists would see through the sham. How might this speak to a zeitgeist of misplaced confidence in the probing mind and intuitions of psychiatrists as if they can see into the soul of the person? And how much this might speak to societies misplaced confidence in authority figures in general? My own psychiatry professors spoke to the medical student with amusement about a public seeing psychiatry as a fraternity of seers who could almost “read minds”. They knew the obvious truth of their own limitations. But why just amusement? There’s the sense in which they were not just amusement with the level of public over confidence. They reveled in it. They liked it. The very fact they were not as horrified as I was at even the countenancing suggests more than a little comfort with the idea. The psychiatrist is then inclined to imply “don’t be silly. A seer I’m not. A prophet I’m not. But a sage? Of course!”.
Finally, after Rosenhan’s findings were informally distributed on the psychology/psychiatry grapevine, yet before they were published, one institution took umbrage at the prospect of being scammed. In their hubris they believed they would not be fooled a second time round. Rosenhan took up the challenge and announced that sometime within the subsequent 3 months an undefined number of pseudo-patients would present to their admissions department. Of 193 patients admitted, 41 were thought to be Rosenhan’s pseudo-patients by a member of staff, 23 by a psychiatrist, and 19 patients were thought to be fake by both a psychiatrist and one other staff member. These numbers are staggeringly high given the staff would have excluded many out of prior familiarity. Every hospital has many patients who are so called frequent flyers. These would not have been suspected due to their chronicity with the service over months or years, and so would effectively reduce the number of potential suspect malingerer/pseudo-patients somewhere below the number actually admitted within the 3-month interval (i.e. to far less than 193 suspects). But this adjustment needn’t be necessary, as the joke was on them. Rosenhan did not send a single patient their way. He just sent them the idea of a fake patient. How many fake patients slip through a system when arrogance doesn’t have its guard raised? Of this we can only speculate. However much we may sympathize with those who believe in psychosis, it is an article of faith there are any authentic psychotic patients at all.
But of course, that is the issue is it not? Rosenhan’s study can easily, though not as easy as some may think, be rebutted given its artificiality. Most people who say they hear voices are justifiably assumed to be sincere. Parenthetically, another population of those who may not be so sincere are those evaluated by forensic psychiatric services. Forensic psychiatrists cannot as a matter of manifest fact discern if an individual’s social mischief is driven by a complete break with reality in the general sense, and a break so great as to have rendered them ignorant of the law. All they have is the patient’s narrative of what was the patients state of mind at the time of the crime, that and their own psychiatric hubris to see through a con. Though not a forensic psychiatrist myself, I have seen many a patient given an insanity defence. From my own conversations with those same patients, what incidentally emerges when the rapport is up and the guard down is that they did the crime for no other reason than self-gratification or the passions of emotions, in full awareness of the law and often with steps taken to evade it. They may or may not believe they are the queen of Sheba. But that is not why they committed the crime.
The question of Pseudo patients aside (i.e. malingerers), there is a remainder. Of these we might ask not if they are lying successfully to us, but if they are lying successfully to themselves. And we might wish to ask just what is so special about the symptoms of hearing a voice or believing unusual things as to make ostensive sincerity meaningful, especially when freedom is at stake?
What is psychosis?
So-called psychotic illnesses go by many different names under several different taxonomies, the most pervasive being DSM and ICD. These and other systems are partially arbitrary social constructions.
Taking the criteria of schizophrenia as the archetypal psychotic disorder, as per DSM 5, criteria include one or more of the following;
-psychotic mental state pervasive over time (not 5.9 months but 6 at the least)
-correlated with social/occupational dysfunction (always easily able to argue for this when one wishes. What is the objective metric of adequate function when one is upsetting to self and others?)
-not explainable by drug poisoning or intoxication (but convenient for psychiatry, recurrent drug induced psychosis will be treated pragmatically as if it is schizophrenia anyway. The next step beyond treating “as if” it is schizophrenia is to reformulate as being schizophrenia triggered by drug use, where schizophrenia or risk is a constitutive proto illness of the patient themselves. The next stage is to imagine them as having schizophrenia where drug use is not the trigger but a symptom. The cause and consequence are inverted. One way or another the relational centre of gravity shifts from drug to person)
-and not part of an illness that is explainable by illnesses as diagnosed by physicians (such as brain tumours etc, i.e., real medicine where the signified is objective as opposed to language games within language games)
Delusions: broadly speaking a delusion is believing something that the politically incorrect might say is crazy, a belief tenaciously held despite evidence to the contrary or in the absence of evidence to confirm it.
Hallucinations: refers to the five basic senses. A hallucination is experiencing the perception of a sensory stimulus without any such stimulus as objectively having issued from the world. The most common example is auditory phenomena with semantic content, so called “hearing voices” though no one actually uttered the words heard. Needless to say, tinnitus does not count.
Disorganized thinking: insomuch as speech reflects thought, the speech does not make sense. Ergo the thoughts also are muddled. Talking nonsense in other words, hopefully this book not being an example. This is to be distinguished from problems in articulating fluent speech associated with bone fide brain pathologies as can occur following stroke etc.
Disorganized behaviour: the behavioural accompaniment or analogue of disorganized thinking, the actions are not goal directed and do not make sense. Once again, the behaviours cannot be explained by bone fide brain pathologies (or the epilepsies as physiological paroxysms with objective biological correlates).
Negative symptoms: the absence of flourishing and expressive behaviour and thought, examples being amotivation and laying around all day, not showering or engaging in the world, perhaps even lacking animation in dialogue with oneself.
Here I’ll focus just on delusions, auditory hallucinations, and disorganized thinking, to argue just how fragile is the concept of psychosis.
What is disorganized thought?
In ordinary human life, thought is expressed semantically and syntactically in speech acts. Putting aside radical post structuralist critique of language we’ll make certain assumptions. Words themselves have meaning. Words are articulated into clauses, these further articulated into sentences. Sentences might be further elaborated to form larger chunks of the speech act. Larger chunks are conceptually equivalent to paragraphs of written text. We expect responses from our interlocutor to address the theme or question asked. We expect the response is intelligible and directed to the goal of the conversation. “How is the weather?” one might ask. An intelligible thematically relevant response might be “it is raining. Do you want to borrow my umbrella?”. Volumes can be inferred from such a response, all the way from assuming certain perceptual integrity (that they know it is raining), conceptual and cognitive functioning (linking “weather” with “rain” with “umbrella”) and capacity and willingness to relate in social ways (offering an umbrella).
Problems arise when the speech act, and by inference the thought, lose architectural integrity. Milder examples might include a simple lapse of logic as might be expected in common discourse. Or it might include highly intelligible responses that nonetheless have absolutely no relevance to the question asked, leaving the listener wondering where on earth the response came from. Broadly speaking these responses might be called “tangential” (by way of invoking a geometrical metaphor), or knights move thinking (in reference to the nonlinear jump of the chess piece). The irrelevant responses may continue to trail off and never find their way back to the point. If I ask about the weather and the response is perhaps a brief entry into the topic followed by an irrelevant completely out of place poem about a horse, this is a tangent. It is to be distinguished from meandering conversation. In conversation, people can travel together from town to town sensibly. They do not suddenly find their companion in one continent having stepped off the boat together in another. There are gradually greater manifestations of thought disintegration down to what has been described as word salad. Here even the words within a clause have nothing connecting them together, as if one if hearing randomly generated selections from the dictionary. One may speculate that in some cases mutism may represent the severest form of thought disorder, where thought is so degraded or muddled that it cannot find its way into any act of speech at all, perhaps from the crowding together of whatever preverbal chaotic soup lay in the mind of the patient who might be psychotic. I’m inferring this from having had patients starting with mutism and working up to salad and beyond to fluency. Nonetheless pure word salad is rarely seen by psychiatrists. Most utterances contain at least something intelligible.
Whilst at first blush these and other examples of so-called thought disorder might be considered psychotic, the crucial question is if this easily separates the mad from the sane, the “them” from the “us” i.e., if ostensive thought disorder is necessarily psychotic? What justification might there be to draw the line here and not there or nowhere at all. If not at all, then ought we avoid overplay the significance of the phenomena. It is remarkable just how common thought disorder is when one looks for it, or rather listens to it. Take for example the audition, the first date, the anxious talk with a powerful other and many other situations besides. Think especially of conversations between anxious poorly educated ineloquent often drug addled patients of marginal intelligence who have their liberty threatened. There is the pressure of stating their case for freedom before a psychiatric authority figure who has the power of the state behind them. What we normally pass over in virtue of the context, empathizing with the person and filling in the gaps where we can, we miss just how thought disordered we have all been in the past. A cancer is a cancer is a cancer, whereas thought disorder is not necessarily anything to do with medicine, and rarely so severe and enduring over time as for the physician to conclude that the person cannot function in the world. Thought disorder is also relative within the world of the “normal”. A philosopher who parses ordinary speech through the severe rules of pure logic would probably conclude most psychiatrists are extremely thought disordered. So what?
What is a delusion?
The DSM III- through to DSM IV TR defined delusions as “false beliefs due to incorrect inference about external reality” whilst the DSM 5 defined delusion in much the same way and pulled in the technocratic buzzword “evidence”. It’s definition reads “fixed beliefs that are not amenable to change in light of conflicting evidence”.
The DSM 5 also defines a subtype of delusion as bizarre ““clearly implausible, not understandable to same-culture peers and not derived from ordinary life experiences”. Pray tell what is “clearly” the case? Bizarre delusions can also be defined as that which is impossible on first physical and biological principles (such as having a full sized refrigerator up your nose or being a woman with XY chromosomes, a penis and testicles)
Kaplan and Saddock, in their text commonly used by psychiatric residents defines delusion as a “false fixed idea not shared by others”
The Oxford handbook of Clinical Psychiatry is more detailed, stating a delusion is a
“pathological belief which has the following characteristics
-is held with absolute subjective certainty and cannot be rationalized way
-it requires no external proof and may be held in the face of contradictory evidence
-it has personal significance and importance
-it is not a belief which can be understood as part of the subjects religious and cultural background”
Let us examine these elements of these definitions.
Falsity
“What is truth” asked Pilate. This was Pilates jaded response to Christ after the latter stated that he was, in a sense, the manifest personification of truth. Despite this being at odds with what Pilate the pagan no doubt believed; he washed his hands of the matter. The rest is, as they say, history. Nevertheless, what was perhaps a rhetorical question for Pilate becomes one about which we might demand an answer. And not just a question of what truth is. The crux of the issue when subjective truths collide is when, nay if, we ever have licence to label some beliefs as normal/acceptable and others as “pathological”. Embedded within this question is the assumption there is and ought to be a “we”, as opposed to a collection of “I”’s. Let’s see if this is the case.
So, an atheist, Jew, Christian, Muslim, Pagan and a schizophrenic walk into a bar. The Pagan says there are many Gods, the “Abrahamists” say there’s one, the atheist says there are none, and the schizophrenic says he is God, or a prophet or maybe both. He knows this as the devil told him so. Or like a latter-day Moses with the burning bush, perhaps he received his divine ordination from the 5G tower. Its hard to remember. The others do not agree with him. None of the other believers can agree on the substance of their own deities, or the metaphysics of his/her/its/their extension into creation. Before a ruckus arises, the party are distracted by a debate between another who says the Earth is flat and yet another who says the Earth is spherical. This splinters off into a debate between the atheist and the Christian who, as it turns out, is in the fundamentalist tradition of Archbishop Ussher. He believes the age of the Earth is more or less six thousand years. A Vedic pipes up. He believes people have walked about the Earth for an aeon. Another eavesdropping pair then are triggered into a debate over the fate of the Earth, whether the weathers will change towards the heralding of a new ice age or the polar caps will melt and the Himalayas become beach front property. In every exchange the protagonists have one fist shaking while the other. Some hands hold “peer review” papers or they write website addresses in accord with their evidence and their anecdotes of personal experience. And then things get nasty over the subject of the current US president and Brexit as the bar patrons start tearing the place apart. This upsets or amuses the schizophrenic. He may either believe he is the president or is maliciously followed by CIA agents of the same. The bar is very large. Echoes of other arguments can be heard, clauses and fragments where we can barely make out the words abortion, vaccination, proper parenting, gender, veganism and more. All are talking facts and evidence. Promptly we depart into the cooler night air.
A moments reflection reveals the obvious. Every adult human being on the planet (or disc as the case may be) has multiple beliefs that others ardently consider are false. Some believe a leader is a proto fascist. Some believe he is saviour from fascism. Some believe the Earth is doomed whilst others consider such a proposition scaremongering. Some believe in Gods and Goddess’. The atheist steps out of the materialist manifold of space and time into metaphysical space to proclaim there to be nothing present save for transcendent nothingness where even the semantics of nothingness itself loses meaningful sense, as does his materialism in taking the transcendent step in the first place. In other words, he is a dogmatist and walking contradiction. And we are all familiar with the potpourri of the other religious traditions that do not define themselves through the radical negation of the atheist. Return we do to Pilate, only now we are he. “What is truth” we now ask. But this time the question comes with a twist. Instead, we ask “Who has the political right to discriminate between all possible falsities”? Whether you have had the misfortune of having been labelled schizophrenic or not, somewhere someone on some matter will think you are wrong about something. They will think you are very very wrong. In fact they will think you are so wrong that they will conclude you are crazy. You will think the same as them about them. Moreover, not just someone will think this, but everyone. Fractionate each and every belief that you hold and seek another who disagrees with you. Sooner or later the group who unanimously agrees on all matters will collapse to n=1, i.e. you yourself, the individual. And this is if you are un/fortunate (or boring) to have stable beliefs. Persons within themselves change their views over the course of a lifetime or even a day. Falsity thus must give way to liberty within a rule of law or we all become tyrants whilst simultaneously all becoming delusional. Or as Christ might have told Pilate, if one does not agree then go in peace and shake the dust off one’s sandals on the road out of town. In this sense Christ and Pilate might have agreed. But Pilate, like the psychiatrist, was not a philosopher. He was a political actor. He managed a problem.
Fixedness
Fixedness and resistance to contrary evidence are both often coupled together in defining a delusion. But a) fixedness or “commitment to belief x” as separate to b) imperviousness to contrary evidence that x is wrong is c) somewhat of a tautology. After all, why would one wish to uncommit from a belief if not the resultant from conflicting evidence or some modifying factor. Whether this evidence be from reason, empirical observation, or some other kind of revelation (with an upper or lower case “r”) is important but we will pass over it for now. The feature of fixedness (of belief) is too close for comfort to the meaning of falsity. Both are intimately informed by, and dependent upon, changes in what one takes to be the calculus of evidence, not sitting in parallel to it. Are the psychiatric intelligentsia sure of what they are saying when they throw out words which blend and weave into one another without a coherent explication of the sense in which the words are used in relation to one another? I’m sure they are not.
One way we could conceive of fixedness is in terms of fervor, an intensity with which the belief is held irrespective of the evidence base. Yet fervor is something more of the passions is it not? Fervor does not relate to the dispassionate deliberation over a proposition in rational and empirical terms and the certainty of its truth. Even this is an artificial separation. Belief is usually held with some kind of attachment, some affect, some quanta of passion and fire within the vector of intentionality towards the proposition. Are we proposing that every human being ought to be a kind of hyper autistic rationalist? Is passion to be made the enemy? This is patently monstrous! Or are we to medicalize the individual for how far they behaviourally go with the belief dearly held? But then behaviour is a different matter to fixedness of the belief as such, though the same in a different sense as one informs the other. More language games and higher order thought disorder from those who cannot grasp phenomenological wholes.
The concept of fervour is often called “delusional intensity”. It brings to mind the patient who was once admitted against their will as psychotic for the beliefs he held against tattoos. He believed they were ugly, representative often of satanic, violent, and anti-virtuous symbology (especially in men). He believed they existed like bad architecture to mar the aesthetic landscape and damage the spirit of the community, surely leading to the corruption of morals now and down the track. This belief was not held with any greater elaboration than that that of a social critic and unusual tattoo-phobe. It was not lost on me that the referring private practice psychiatrist was, under the expensive suit, an aficionado of, and personally stained by, many tattoos. On the other hand, I personally could sympathize with the patient, recalling a time when only bikers, convicts and sailors sought out the tattoo parlours that were few in number when I was a child and always in the seedy back alleys of town. Today it’s a rite of passage for almost every young man and (especially) young woman to have a skull, sword, six pointed star, flower, narcissistic quote or an epitaph somewhere on their person. Some tattoos are beautiful. Many are not. But you see this belief was strangely passionately held in this specific young man. He took it upon himself to evangelize against ink, chastising those he passed in the street, occasionally preaching it on the corner. This will not do. Consequently, he was described as delusional in virtue of holding the belief with “delusional intensity” on one hand and given the attendant “risks of misadventure” on the other. For, or so the argument went, if he annoys someone he might be assaulted, and he must be protected against the misadventure that his “illness” might bring upon him. Psychiatry would not consider the idea that perhaps he ought to be free to speak his mind. On the other hand, those who might assault him ought to face the police and the judiciary and other kinds of incarceration. Likely he would reconsider preaching after that. But no, psychiatry takes it upon itself to manage the risk. Worse still, his family insists psychiatry ought to bear it. Such is the erosion of responsibility in the ideological age of hard neuroscience. No one is accountable for what they do, the victim is the criminal and the criminal the victim. Despite my protest, this patient was accordingly detained and treated against his will, without the slightest engagement with his ideas. Neither did psychiatry engage with the idea that behavioural fervor is the stuff of many adolescents and all revolutionaries of all religious/irreligious and political stripes. It is the stuff of those who are true to their beliefs. To paraphrase Vaniegem, a revolutionary without action speaks as with a corpse in his mouth. There was no formal difference between he (our patient) and they (the revolutionary). And if a patient were not true to his/her beliefs, might it be argued that he has negative symptoms, depressive amotivation or some other symptom of mental illness. Damned if you do and damned if you don’t to a system who wishes you damned.
Or in talking about fixedness are we speaking of lack of openness to change. Synonymous with stubbornness, this perhaps rigidity is as much a passion as the fervor to persuade. Take any case of someone’s professed faith in who they are, who they were, who they will be, what they will do and how they will evaluate the world, including significant others within it. What are your cherished beliefs? Would you, as a fundamentalist Christian, when presented with fossil evidence and geological dating not just conclude that six thousand years ago God created a shabby chic Earth that just happened to look older than it is? Or that the science has been corrupted by the father of all lies, i.e. Lucifer? Or would you, the atheist, if waved at by a statue of the virgin not conclude that against almost infinite probability all the vibrational states of the atoms of the marble moved in the same direction at the same time, and further than one would expect. Or you might think the quantum probabilistic field within which the atoms reside synchronized into what may be thought of as movement? Or the miracle could be interpreted as little more than the playing out of Clarkes first law, that any sufficiently advanced technology (or scientific knowledge perhaps) would be indistinguishable from magic. In this case the miracle is scientistically explainable. What would the virgin then need to do to get your attention? Or maybe nothing would convince you otherwise that Lee Harvey Oswald was a patsy, or that the Apollo 11 really did, or did not, land on the moon. The old chestnut of conspiracy theory is that it is in the nature of conspiracy to sometimes cover its tracks. Would any of you betray your Marxism, despite it not yet creating the utopia each time it is tried in the world. Or would you believe in Marxism if told it wasn’t ever given a fair chance? Would you ever rape your own child, or believe such an act to ever be morally justified? I’ll guess you would not. But how can you be so sure in your fixedness of what you won’t do tomorrow, when asked questions about moral givens? Why are you so fixed in what I assume your answers to be? Would you give up believing in the fidelity of your husband even after seeing his strange phone records and he tells you that man in the singles bar just looked like him? There might be valid explanations either way, and fixed beliefs also. Just as is the case with what we believe to be false, we each hold beliefs that we will doggedly hold to the end. Damn what the so-called evidence shows. Whether the evidence be “science” or material evidence or journalism or the well intentioned friend judging you “crazy” it makes no difference. So what?
The criterion of fixedness also calls to mind the patient who recalled vividly (and I would say symbolically), a time when “military police” took him in the night, anaesthetised him and replaced his liver with a mechanical version. Now the party line in psychiatry is that we ought not entertain such delusional ideas as his by hypothesis testing such as X-raying for metal livers. For such would, as it were, play into the hands of the patient’s psychosis. Strangely though this kind of hypothesis testing is just what the doctor orders in the methodology of cognitive behavioural therapy for the neurosis such as anxiety and obsessive-compulsive disorder. But such hypothesis testing is discouraged in psychosis. As luck would have it, for some reason we had medical cause to perform an abdominal CT scan (essentially a glorified Xray) on our cyborg patient. Lo and behold no mechanical liver was visible. We accordingly challenged him on his belief. Our latter day Prometheus accepted without protest our “evidence”. He agreed he does not have a mechanical liver. Without skipping a beat he immediately concluded that at some time the buggers must have taken him in his sleep yet again, replacing the mechanical liver with a real one of flesh and blood. Well, that flexibility puts paid to fixedness of belief. Or does it? Is he truly delusional then? I can always shift gears myself and crucify him on the cross of psychosis for what he did believe occurred in the past, for even believing it was possible and being fixed on the impossible past. Yet what have we proven save for our own guile to nail someone and keep them nailed if we are so inclined, to keep them in the clutches of psychiatry.
So let us drop the word fixedness altogether and simply approach the issue of belief held in the absence of confirming evidence or in spite disconfirming evidence. Does this not return us to where we started, with the matter of falsity and what constitutes evidence? What right ought the state have to interrogate anyone on how they arrive at the beliefs they hold? How might the state and the guilds of psychiatry themselves have arrived at the final answers to the deepest questions of epistemology and the assumed value of truth, when the philosophers haven’t managed the same? Belief in psychosis is also fixed, and social engineers can practice with a fervor better described as “delusional intensity”.
Cultural Context
The Oxford Handbook of Psychiatry (as do all psychiatric guilds) makes a most curious qualification, i.e., a belief can be appropriate if it is held as flowing from the “subjects” own cultural background. Putting aside the subjectification of the individual by use of the very word “subject”, it’s a very traditional British formulation. The requirement of own background is quite at odds with the current state of affairs in a multicultural post EU UK. Its also at odds with the individualistic spirit of the Americans. How many who court beliefs fully developed in another culture may be captured into the net of satisfying such a criterion, at least being on their way towards, as the Handbook states, a diagnosis of “pathological belief”? The situation calls to mind all the stories of the westerners who becomes disenchanted with traditional Christianity (or probably just bored and looking for novelty). And run away they do to join the Ashram, only for the Guru to state that they cannot be Hindu and are best back in the Anglican Communion where their karma intended them to be, with the Father, the Son and the Holy Spirit rather than Sat, Chit and Ananda. Would psychiatry also seriously entertain the possibility that someone was delusional if embracing a cultural belief incongruent with their own background? Would the white upper middle class suburban youth meet the criteria of incongruence with their own cultural beliefs and practices if they adopted the persona of the urban black rapper? The list is endless, tacitly suggesting to us that we ought to know our place and ride in our lane. The subtle hints of identity politics lay everywhere, hiding in plain sight.
Let us then be more individualistic and say that someone cannot be delusional if the belief is part of any cultural and religious background, giving them freedom to escape their own cultural backyard. Then the question of background itself comes into view. Is this not a war against the individual and against progress that they must attach themselves to an identified state approved antecedent and cannot formulate their own culture? How far can the thread to the past be stretched before a belief becomes, sui generis, unique and accordingly vulnerable to being declared pathological? Was Christ or the Buddha sane in forming a religion out of an existing one (Judaism plus/minus Platonism in the case of the former, Hinduism in the case of the latter), i.e. both being culturally congruent with something that came before? Or insomuch as the new religions they founded were radical departures to all that came before, were their beliefs pathological, i.e. psychotic? Surely this is a case that can be made, that all pioneers are insane? Founding fathers of many a paradigm shift in science fall into the same orbit. We can easily imagine a counterfactual history where Christianity sat side by side with a psychiatry, moving from the schizophrenic megalomaniac madness of Christ himself to that of a mass delusion and gradually onto Constantine ordering its removal from whatever could have been the DSM of antiquity. Why? Because by that time, it had become culturally established. Psychiatry would have it that the shared belief of the many make it non pathological, though the belief of the one originator is not. They would say the root is rotten, yet the branches are solid and the fruit is ripe. From Copernicus to Darwin we can imagine other original thinkers and doers similarly stigmatized. Perhaps the better proposition is that delusion itself in a sense did not exist prior to its invention as a construct by psychiatry. Just as law created crime, psychiatry creates the pathological belief. This is not to say there is no prior sin and no prior false belief. It is to say we risk starting with category errors and proceeding to even greater nonsense.
None of this drives home the central point. A clause appealing to cultural congruence to categorize a belief as non pathological is, ipso facto, social engineering of the most mendacious kind. It’s a sinister and evil war against the individual. And more contemptuously it the act of the coward bullying the weak. What it proposes is that the beliefs of one prophet or self-proclaimed god or avant-garde thinker can be pathological in virtue of the novelty. Perhaps two or three believers would suffer the same diagnosis of a shared psychosis. Yet when the movement reaches an undefined critical mass, where the people can assemble and take up pitchforks or form a voting bloc, then they are dangerous to power. And only then they are no longer deluded. Then they are a culture, a religion (or negation of) and so on. The notion of the voting bloc is important insomuch as the institutions of psychiatry are thoroughly in bed with the state, having displaced the church and so giving the illusion of church/state separation in the secular western world. Still the form of such an arrangement remains. Psychiatry would do better to admit it’s cowardice. Either that or declare in a coherent way what is and is not a pathological belief, take the ideological stage with the other religions and act (and fight) consistently come what may against larger and smaller opponents alike. Let’s make the truth value of every culture and ideology is up for grabs. Then psychiatry as a culture amongst others itself ought to enter a zone of vulnerability. It’s cowardice is not simply a war against the individual, yet also a want to grant immunity to itself from prosecution as deluded or wicked or both. This is the political form of leviathan.
Belief as such
Much is predicated on the idea that beliefs need to reflect the world. Yet where is the evidence this need be the case all the time on everything? My idea is itself ironically a belief, one which sits outside the material world as it is. Rather it is a statement questioning what beliefs ought to be. And a belief of what a belief ought to be, insomuch as it might better reflect the world, might also have greater survival value, yet maybe not. Take the case of confidence in oneself against insurmountable odds, the hope of a miracle when life is at its bleakest. Often this is enough to survive through great adversity, despite the facts of the world being bleak and likely the outcome being poor. Or take for example the basic thread of the atheistic existentialists, that life is ultimately meaningless and absurd, and so the only meaning is found in the construction of meaning, which is to say lying to oneself. Why a lie? For this reason. This subjective meaning may feel itself to be a victory whilst being subsumed within the greater metaphysics which is cut through and through with inescapable nihilism. One can never escape a transcendent nihilism that reflects back upon, suffuses, and defines, the meaning we think we have constructed for ourselves. If the universe is meaningless then all that is within it contains the same property, including the nihilist themselves and all escapes they attempt to make. Nonetheless, why not allow them their incoherent fantasy. Beyond certain beliefs attached to basic survival (the blind man thinking a snake is cane), why must we believe in truth? But even with chosen beliefs leading to death, so what?
In any case, the belief about what a belief ought to be contains within itself a moral argument as how we ought to live. And a belief of what a belief ought to be writ large by powerful persons and applied to other persons against their will becomes a political act of the moral tyrant. And moral propositions, however much they may be held as truths, are outside of a basis of evidence the likes of which are the standard criteria of delusion. They are experienced as faith. A belief is also propositional attitude. Hume thought they could be differentiated from fears and desires. I’m not so sure. Where is medicine and psychiatry in all this, except as some entitled child who thinks it has already mastered the content of the philosophical conversation going on for centuries despite it being absent from the table. Does it deserve a place at the head of the table whilst not being able tie it’s dialectical shoes? My suggestion, itself a belief, is primum non nocere, “first do no harm”. If the individual is aggressing against others the job of the minimal state is to police, prosecute, deter, prevent and deliver justice. If not aggressive, leave the person alone. Now you might ask “but what of beliefs harmful to the one who holds the belief”? So what? What one believes is more important than the life of the body. If another wishes to die for their belief, love is the respect you grant what they hold dear. Their inner life does not reside in, as it were, the beating of their heart. It is in their beliefs.
Beyond the Phenomenological horizon of Jaspers
Is there anywhere or anyone else to which or to whom we could turn to know what delusion is as opposed to just another variant belief about which we might say “live and let live”? Well from the frankly silly little unconvincing aquarelle that is the definition of delusion we have discussed, we come to the thickly obscured canvas of phenomenology. Its obscure as from Lambert to Brentano to Husserl to Jaspers et al, philosophy cannot seem to agree what phenomenology is (because it isn’t, but that’s another story). Nonetheless I’ll try my best. Broadly speaking, phenomenology is the study and taxonomy of mental phenomena with the goal of establishing the basic elements of experience and the vectors of relationship of one experience to another. If done alone and with reference just to the self, it’s the ultimate in omphaloskepsis. Here’s an example, I may have a fear. The fear is usually directed towards something (the directedness or aboutness being an “intentionality”), where the fear contains within itself a representation of the feared object. This object need not be an object in the physical world. It can be an idea in the abstract. What are the qualities of the feared object as experienced in the mental state? How does fear stand in relation to belief, sensation, desire, planning etcetera? When did it arrive in my consciousness and what were its antecedents, if any? This sort of thing is phenomenology. So far this is simple to grasp, though matters get trickier if we are to consider ourselves, our identity and selfhood, themselves as objects of descriptive introspection. To do this is to stand apart from phenomena. But what is the self standing apart from the self? Arguably this degree of separation obstructs from knowing as a true phenomenologist attempts to know, i.e. in purely unadulterated subjective terms, where being and self are one. Only then can we know what it is to be. But then what can we say about this raw “beingness”, without holding oneself out at arms length, in so doing losing grasp of what it is to be? Is the reader confused? Good! These more metaphysical speculations that takes phenomenology from the realm of banal descriptivism to existentialism and even the outer suburbs of more mystical cities. But such sojourns off the clear and simple path fortunately or unfortunately were never used to evaluate and contextualize how phenomenology might be appropriate for psychiatry. They should have. Why? Because the banal is always subsumed within the higher metaphysical orders which either validates the former or repudiates it. That is to say, if psychiatry cannot wrestle with the big picture, it has no place claiming ownership over the small. A pity as these are the very questions crucial before engaging with Jaspers. My engagement with Jaspers will be the simple Jaspers as taught to psychiatrists, not an expansive review of the man and evolution of his thought.
Karl Jaspers, the prodigious and morally upstanding psychiatrist turned psychologist turned philosopher more than any other allied (his version of) phenomenology to psychiatry. His only idea filtering down into psychiatry is the notion of “empathic understandability”. Jaspers project was to engage the patient with radical empathy, though I would say not radical enough (vide infra). The task is to place oneself within the mental shoes, so to speak, of the patient. The task is to listen without judgment to all the inner experiences of the patient, their relationship with one another and with the temporal chain of events in the patient’s narrative of their inner (and outer) world. This was the method, the goal being deep intersubjective understanding. And so you might encounter the patient who believes their spouse to be unfaithful. How and when did they come to arrive at this belief? Do they believe their spouse is unfaithful after coming home late at night, being seen in town with an ex girl/boyfriend, smelling of a unfamiliar perfume etc? This Bayesian line of reasoning is something with which anyone could say they empathize. Infidelity still might not be the case in truth. Nonetheless we can empathize with the patient’s belief the spouse is unfaithful. We know “where they are coming from” even if we disagree or sit on the fence.
Or did the belief arrive in consciousness like a sudden migraine one morning, in blazing certainty and in the absence of any antecedent experience that could constitute “evidence”, where evidence is a chain of thought and experience with which the psychiatrist could empathize or fail to empathize as the case may be? That is to say, are they claiming just suddenly to “know” the spouse is unfaithful. But how could such a certain belief reasonably arise de novo? Or did the belief arrive in consciousness as a result of thoughts and experiences the likes of which the psychiatrist, try as he or she might, fails to empathize as logical or common-sense entailment, say for example if a letter arrived in the mail with a stamp askew or upside down on the envelope. “Then I knew he was cheating on me” the patient says. “How this event (the askew stamp) entails or leads to the belief in the other (the infidelity) is beyond me” the psychiatrist will think. This is the psychiatrists unsettling experience. Try as they might, they cannot “see where they are coming from”, making impossible the act of empathy. Such empathic un-understandability need not appeal to any definition of delusion as earlier described. The belief instead being formulated and understood as the product of a process. The un-understandable belief passes beyond the horizon of phenomenology. And so the experience is considered delusional, and the person is considered psychotic. Philosophy then becomes medicalised (diagnosis) and micro social engineering then begin.
So far so good, but is it? Take the matter of the beginnings of the delusional journey. We have the stamp then the belief about the spouse. Yet there is often a stage before both. The phenomenological journey between psychiatrist and patient may reveal an initial phase before the formed system of beliefs that are the alleged delusions. Before the stamp there might just be a free-floating sense that things are not quite right in the world. This is the so-called delusional mood. Or the belief may arise as stated in a flash, without reasoning, an autochthonous formed delusion, as in Chekhov’s Ivan Dmitritch” of Ward 6.
Coming upon a revelation or sudden awakening, insomuch as one cannot identify readily an antecedent thought, is un-understandable. But is it? If we permit the possibility of the existence of the unconscious, how can we say what is primary and what is autochthonous? How can we say what does not have understandable priors? Think of times your conscious mind worked on a problem, say a math equation. It may take you thirty minutes from first encountering it to the final solution. If you are interrupted in the first 5 minutes, the answer may come along in a flash some minutes, or hours later without the conscious mind ever returning to the problem. The total conscious time taken to solution was in the latter case substantially less than thirty minutes. Obviously, the unconscious in its mysterious machinations was working on the problem all along. We have tentative evidence for the existence of the unconscious and that it can problem solve, though we know precisely nothing more of what goes on in it, and nothing at all of its architecture. Think also of what other problems the individual faces and “works on” all the time. Someone one day experiences a sudden sense that things are not quite right. They look upon the world as something alien, a vast instrument laid out before them that has suddenly fallen out of tune, with all the movements of the persons and machines around no longer melodious. Now there is just cacophony, metaphorically speaking. Between their slumber in normality and this allegedly psychotic first moment has been an interim. Inn that interim their psyche has been exposed to the banal, the kitsch, the consumerism, the media, the rising sin, the fading virtue, the bucket list that just keeps getting fuller, the loss of youthful innocence, the unwelcome arrival of adult responsibility, the growing middle aged crisis, the unwelcome arrival of old age, the realization of mortality, the looming seven year itch, the baser drives seeking justification, the crowds and changes and so on and so forth. The list is limited only by one’s imagination. One day something starts to crack from all these exposures, the scales begin falling from their eyes. Something is not quite right. Now we may debate what the allegedly psychotic may conclude from and following this first move into alienation, whether the investigations (i.e. the thoughts) that come after the delusional mood and first autochthonous shift are psychotic or not. Yet how on Earth can we medicalize the shift itself? How can we say the sense of something “not quite right” is itself delusional? It has no predictive validity in advance. We must de-pathologize the idea of delusional mood as it (technically speaking) also lacks discriminative validity. I’ve lost count of the number of persons I’ve encountered who woke one day, realized pre-rationally (or arguably trans-rationally) that something was wrong in the world or at least their world. And this disquiet rumbled within them towards great changes in their lives, perhaps even by that afternoon they had found religion, a divorce lawyer, a resignation letter, or a caravan out of town. Are we to suggest intuition must be logical and positivist? This is incoherent.
Another problem is holding patients to an account of justifying their basic (i.e. autochthonous) beliefs. This too is quite unfair. Why? Even those who work in mathematical and so-called scientific investigations must rely on assumptions so basic, so sui generis, that they can only be operated with, yet cannot be explained in more atomic terms. Vastly complicated technologies rest upon mathematics. 2 add 2 equals 4. But where is 2 and where is 4 and why is the latter the square of the former? It just is in some way that is either a matter of faith or radically ontologically true, whatever its utilitarian value. One can operate with these assumptions as knowledge yet one cannot justify the assumptions as knowledge. For in what sense can I claim to know? I cannot get below or behind or prior to these assumptions. I can walk forward in knowledge, operating with tautologies and basic assumptions. Yet what have I added to say “I know” what I believe when it comes to basic beliefs themselves. All this is to say no one can justify vital core beliefs. Ultimately, we can become empathically un-understandable even to ourselves. There is no way outside the trap.
Or what of the friend who can describe their ideal mate, yet when he/she comes along they feel nothing or might say they know (i.e. believe) the person is not right for them. Instead, they can only feel attraction for someone less ideal, often far less ideal? Will we not fail in empathizing with our friend? Are they then psychotic? Or might we subscribe to a belief in man’s fundamental drive to self-destruction? But then this is self at odds against self, also psychotic. Or what of the friend who, despite evidence to the contrary, says they intuit “I just knew he/she was/wasn’t right for me. I don’t know why I know”. Why are these individuals also not psychotic? Is it because we empathize with the metaphor of “the chemistry was/wasn’t right”? Is it because we accept the place of intuition, even if we question its application? Have we shared in their psychosis? There is no way outside the trap.
In summary, However strange, it is most unfair to look for the patient’s basic experiences and beliefs, the hinges upon which other beliefs and behaviours may turn, and then to expect them to justify these basic beliefs when no one alive can do the same on every thought that forms the basis for action. It would be a trickery were the psychiatrist not so ignorant.
Another problem arises how we may accomplish this when embarking on the empathic journey with at least one preconceived goal, that of empathic understandability itself. This is a goal which smuggles along with it all the prejudices Jaspers sought to avoid, or ought to have avoided. In his writings he speaks of the pathological belief as if it is a priori something that exists as separate from the non-pathological, just waiting to be understood, or rather I should say identified by its un-understandability. The very notion that one may in principle reach a point of empathic un-understandability and that this somehow fleshes out an objective psychotic situation is only one such prejudice. Many other covert prejudices eat away at us without our awareness. One example is the limitation of symbolism as permissible as concrete belief and a mode of life. Another is that a lie to others is not pathological whilst a lie to oneself is. Yet another is the risk I may have already decided the patient is delusional and I use Jasper’s method to justify what I have already adjudicated. Now surely to engage with the phenomenology of the patient entails an identification with the patient in all their psychic experience, perhaps even unto an entering into the alleged madness itself. To truly stare into the abyss is to look headlong, with the unavoidable result being that the abyss stares back at you. Only now you are the one staring out. And when one achieves this ultimate act of empathy, then where is the madness? Perhaps back in the world of the accusers, back in the world of the allegedly “normal”. Might Jaspers horizon say more about him than about the patient, and how un-intrepid psychiatrists are in making the effort to empathize as the Jaspers known to psychiatry might have suggested to us? Or worse it is a show trial leading to the justification of the charge of madness by the judge who is also first the prosecutor but really a cheap sophist? Who is empathically watching the one with authority to judge by empathy?
Let’s take the following examples of patients who would, and indeed were, surely diagnosed as psychotic and who were treated forcibly against their will with powerful tranquilizing (domesticating) medications and involuntary hospitalization.
There is the case of the young lady, typical of several female patients I’ve seen over the years. she comes to believe she is being followed by some powerful presence and persecuted by all and sundry. She believed that her body was literally behaving as a marionette, with her abusive ex-boyfriend pulling the strings and controlling her every move. Sometimes she would move her lips and tongue to speak, her ego cut off from identifying herself as the agent behind the voice who spoke. It sounded like a woman’s voice she would admit. Indeed, to her ear it sounded identical to how she imagined and remembered her voice to be. Nonetheless the voice was that of another she would say, and the speaker was a male. This belief was held literally. Her thoughts also were not her own. Her own were taken from her. Occasionally when her identity emerged, she would just become what was once termed “hysterical”, and scream violently about her rights as a woman (her words), surely a clue to any with even a modicum of curiosity to ask the deeper questions. Now let us break this all down. No psychiatrist I know would let her go free, let alone tolerate her beliefs as another kind of normal, a damaged normal I’ll admit. Her beliefs were unfounded in ordinary terms of what might be considered evidence. Technically they were considered “bizarre” delusions. People do not possess other people and cannot control them as one would control the movements of a puppet. When my arm raises it is I who raise it unless another holds it and moves it and is observed to be doing so. Who can empathize with the impossible? But let’s look at her from a different angle, one not wedded to psychiatry at all as to what psychosis and schizophrenia is. What if she had been used and abused, perhaps even prostituted out by men (plural) in the past? This indeed was the case. What if her opinion came to naught and her body was not, in a sense, bio-politically her own? And what if the man or men whom she loved and towards whom her ego was diffused were using her as the object she once allowed herself to become. I say “allowed” for at one point she did have responsibility over the maladaptive steps she took and the drugs she imbibed. Though compassionate, this book is a defense of personal responsibility, his and hers. To my mind her alleged psychosis was her existential pain writ large to a malignant degree. It was quite easily something with which I could empathize, all considering. True her beliefs were not materially and efficiently true. So what? They are symbolically true. How might we answer such cases, especially when the individual rails against being hospitalized against her will, medicated against her will, and inevitably with a force that unavoidably must on some level recapitulate the sense of powerlessness against powerful others, in this case me as the jailor? With such patients I would rather grant them radical freedom, ideally coupled with radical unfreedom for the vermin men (and/or women) who preyed upon them. I would rather do this even knowing they may never recover as any well-intentioned person would wish them to. In the vast majority of cases psychiatry never can effect such recovery as one would wish. But alas it was never so. Never were similar patients not diagnosed with schizophrenia or bipolar disorder (and sometimes incoherently both). They are always brought to the hospital, by police more often than not. They are always forcibly treated. And the pimp almost always walks free.
Or what of more systematized persecution. I’ve lost count of the number of patients who have some variant of a belief that they are in a kind of Truman Show like experiment, observed by others for some greater amusement in a large cage with them the only exhibit. Often the observers are said to be government or family, though sometimes they can be celebrities or aliens. Unlike the character in the film, they have never seen a lighting prop fall from the “sky”, and almost never ferreted out the hidden camera in their home, though not for want of trying to find it. Yet nothing will convince them otherwise at just how canny the observers can be at covering their tracks. Even I might be an actor they wonder, though most of the time I’m able to avoid involvement, becoming involved only if they think I’m harming them. I’ll let the reader analyse the implications of this shift in their beliefs about me with the shift in our mode of relations, from interested other to punitive other. Anyway, examples of these cases take on many forms. Some came into closer approximation with the film, especially in the immediate years following its release. This should also serve as a hint to mainstream psychiatry that so-called delusions are not likely brain diseases as opposed to psychological creations for which the brain is an indispensable tool for sure, yet not the architect as such. Cancer is cancer is cancer down the millennia. It’s form and content change not. Its incidence can change with the emergence of environmental carcinogens (e.g. as in lung cancer and mesothelioma). But delusions are infinitely more plastic. One generation they are demons and the next generation big media (is there really a difference?). And another generation in another person along comes the Illuminati, paedophiles, biker gangs…..whatever is the cultural material or boogie man of the times. We must bear in mind that sometimes the boogie man is real. The biker gang really is out to get them and there is more than enough paranoia to go around. Sometimes these Truman Show like experiences tread far the plot of the film. They become these other things and many more, with the warfare waged on the spiritual plain. But here is the crucial observation. All of them have one thing in common. It is a feature with which we all can empathize. In each and every case the sufferer is a person of interest. They are important even as they are caged or hated, hunted or abused. They are the center of a kind of an attention the intensity and breadth of which few ever “enjoy”. And I use the word “enjoy” deliberately, though with qualification as their suffering is certainly neither denied nor discounted. Nevertheless, a life of persecuted importance may be perversely preferable to that of bland dissolution into the meaninglessness of the masses. And not just the masses, but often to a lower rung than all those on the ladder. Is it better for some to be Jeanne d’Arc and risk being burned at the stake, than be that nothing little village boy or girl who few knew, fewer cared for, and none at all will remember? If this drive to significance is the primary pathology, this is something about which one may readily empathize. And so is not pathological at all by the standard of those who set the standard (i.e. psychiatry).
Here are some additional cases of maladaptive overdrive to preserve narcissism informing many cases of what we call psychosis in general, or delusion in particular. The first is also from popular culture, which derives its power in part from our capacity to identify with the protagonist. Consider the film Total Recall. In it the main hero is a garden variety construction worker who chooses a virtual holiday in a dream state. Things go awry. He wakes up and discovers himself to be a previously amnestic secret agent, never a humble construction worker at all. Part of the plot concerns the question if this discovery is authentic or part of the dream he purchased? What a vacation it must be to relish in high adventure, and moreover to believe it is true. Even though death lay in wait at every turn, his dream was exciting. He paid money for it. Psychosis comes for free.
The second example is from the life of many persons who thankfully evaded psychiatry. I can recall the world of the 1970’s through to early 1990’s, when huge swathes of subculture were under the spell premillennial terror. I knew dozens of persons who believed the world was coming to an end, the beast of revelation would soon rise and famine, pestilence, and all manner of Satanic and/or secular Communist persecutions would creep over the land, and indeed into their very lives and homes. Some sold their homes as, well, why not when the end is nigh? Were these people facing persecution the likes of which any sane person would prefer to avoid? Arguably yes. But oh, what a glorious drama, as I can tell you from firsthand experience these people were, more often than not, happy and enlivened with meaning. Needless to say, none required medications and most settled in with the rest of the sheeple in suburban insignificance, wage slavery and reality TV addiction come the other side of the millennium. Then and only then in suburbia they became depressed and were psychiatrically drugged. Perhaps Satan won after all. Perhaps all they feared will happen and they were only off on the dates.
The third is an example of a specific patient in real life, who failed to escape the clutches of psychiatry. He believed himself to be a Van Helsing like character. All around him are vampires, including the clinic receptionist. He was not so sure about me and gave me the benefit of the doubt. The risks were real for him too, for these vampires were not likely to grant him immortality and the key to the vampire executive bathroom. Instead, if he failed to maintain moral strength and a strangely described sense of psychic fortitude, they would turn him to mince in a giant meat grinder he was sure literally existed yet could not confirm ever sighting. He thought it was kept out the back of the hospital. This patient came my way when the vampire film genre was all the rage, and he was of the vintage whose unconscious may have remembered the human meat grinder of Pink Floyds music video “Another Brick in the Wall Part 2”. Now I ask you to guess, who would this man be if not the bane of vampires, themselves a metaphor for the selfishness of the world and the meat grinder arguably the call to conform? The answer is this; he would hold a menial job and stand in peril of a confrontation with the fact that his youth was gone, his wallet was always near empty, and he had nothing and no one. In saving him from the vampires, psychiatry aspired to grant him just that kind of terrible mediocrity with the drug it forcibly injected into his backside every 2 weeks. The question psychiatry never asked itself is why they would prefer him to be a victim of the state’s metaphorical meat grinder and not the one of his own psyches creation, most especially when he looked me in the eye and told me that were he not forced to, he would never ever take the medication. Even if the medication seemed to correlate with the vampires losing interest in him, he didn’t want it. Inject him is precisely what we did, as we always do. We bit him where the vampires didn’t and never could.
Finally, every psychiatrist can easily identify the many patients who react in response to the so-called delusions, often to their detriment. Take for example the patient who in looking for hidden cameras comes perilously close to being electrocuted. Or the one who drowns from swimming out too far to avoid aqua-phobic aliens who cannot swim after him. Or the manic who buys up useless old items and travels to the other side of the world in the fervent belief that he can market them at Christies and make a killing, wiping out his life savings in the process. I acknowledge risk and don’t trivialise the gravity of the situation (and more on it anon). and I also acknowledge patients can put their money and lives where their mouth is. Yet neither can any psychiatrist deny the substantial fraction of patients who much of the time or all the time do not behave as if what they (supposedly) believe is true. Just this morning I had a patient who would say he is fixed upon the belief that people are waiting outside to kill him. And by his side is his wife whom he claims is part of the nefarious conspiracy. The strange thing was his warmth towards her, the grin whilst he conveyed this story and that he entered and exited without hesitation or looking back. Why was he not frightened of her or why not gaze upon her with the hatred such a conspirator would deserve? Psychiatry has long written off such incongruences as part of the irrational split, the “schizein”, within the thinking, the “phren”, the incongruent affect etc, the very stuff of schizophrenia. Psychiatry has long assumed this incongruence to be a symptom itself of the disease, not something to be questioned as opposed to just concretizing the diagnosis. I’m not so sure. Likewise, psychiatry ignores the fact that most of the time our schizophrenic can be flexible to changing other beliefs apart from the core delusion, and so clearly do not have a global impairment of cognitive inflexibility per se. Could it be that at some level all of those whom we might call delusional have created a lie for themselves to live by, the degree of attachment to the lie being what we call “lacking insight”? Take a thought experiment, a village of the so called sane. They are told the barbarians are coming down from the hills to rape and plunder. Some freeze, some prepare to fight, some take flight and run away. But all to a man, woman or child would surely react and fly up the Yerkes Dodson curve of anxiety. And all would settle if no barbarians were there and someone made a false call. Now let’s imagine this were a village of schizophrenics. Were these villagers medicated schizophrenics some would do the same and run or fight. Yet they may just lull about in anergic languor as the “antipsychotic” ablate their drive to escape. What of a village of unmedicated schizophrenics or those refractory to treatment? Under the deluded belief that the barbarians were at the gate, a sizable minority of cases would just tell you so and go about their daily business, occasionally peering over the pickets to see what was, in fact, not there. Why would they not all fight or flee? We ought to ask ourselves a difficult question. Is it not conceivable in what is betrayed by the (lack of) behaviour of this subset of schizophrenics, that there are layers of belief? Is it not possible that they are lying to themselves, and part of their psyche knows it’s being lied to?
What’s with the voices?
The psychiatrist enters the room and engages the patient in conversation, only to find they are distracted, their head inclines away at key moments within the conversation as if the room is occupied by patient, psychiatrist and a third interlocutor the psychiatrist cannot see. Mild distractibility is the subtle hint to an intuitive psychiatrist something is amiss, though the cat may be out of the proverbial bag when the patient abruptly turns sideways to face empty air. They then talk as if to respond to a voice telling them this or that, though its rarely that theatrical. The voice can issue a derogatory comment, a commentary or even a rebuke against the psychiatrist and a warning not to trust them. This is a voice only the patient can hear. As with so called delusions, you will probably conclude this strange behaviour not simply the mark of a garden variety eccentric. Isn’t it surely a marker of the insane?
An important point to raise at the outset is that auditory (or other sensory) hallucinations are in practice a phenomenological composite of more than the raw qualia of the percept of the sound itself. Voices are rarely just voices.
To begin with, hallucinations are not entirely separate to the case of delusions. In ordinary cases the only power an hallucination can have is the patient’s belief about the hallucination. A patient may be distressed by a recurrent voice telling them to kill themselves. Yet there is a world of difference between knowing this experience is emanating from their own mind and the belief that the voice is from someone or something else. Perhaps they identify the voice as someone they know or have known. Perhaps it is from a supernatural source. Perhaps they did not know who or what is talking to them. Surprisingly, often they deny having considered the question. But often all they “know” is that it is not them. (This belief is in turn confounded with the concept of insight. See how psychiatry is an intricate web of begging the question). The list of possible external agents is endless. Insomuch as this “belief about” component of the phenomenological whole is notionally delusional, we have dealt with it already. It can be said that the “belief about” the voice (qua delusion) is simply a stubbornness to refuse the obvious. And so, a delusion is a difference of opinion between persons as to what is the case (in this case the source of a voice).
Unless we share in their “belief about” the voice, we would have to say our patient is the architect of the message they are “receiving”. Consequently, they are insane, and in their insanity radically different to the norm? Not so fast. I might tell you that a little voice inside my head told me not to gamble on a car park close to the hospital entrance as this little piece of real estate would surely be taken by another. That same little voice told me that I’d better cut my prospective losses and park in that other street. Having made the gamble and failed to get the carpark, the same little voice may tell me I’m an idiot and ought to have known better. Little voices can be very punitive. You would listen to what I say without raising an eyebrow, all because my turn of phrase “little voice” is metaphorical. I know it. You know it. And you know I know it. At worst what is pathological about the hallucination of hearing voices is the conversion of the metaphorical (and perhaps also the symbolic) into the literal hearing of an inner speech act, where inner speech is a metaphor for thought. Abundant evidence, even neuroscientific evidence, can at least be said to support the model that the auditory hallucination is disavowed inner speech. That little voice in the heads of all reflective persons is something heard. There is even some evidence, on at least some occasions, of excursions of vocal musculature during the hearing of the voice. Though the throat does not make sound, they literally are talking to themselves. Why hear it as opposed to think it? Why not? Can hearing a thought not be conceptualized as a normal variant of human experience? The patient’s belief about the voice is a delusion, something already dealt with. Unless we see them distracted as if by a sound, we cannot even know they heard anything. They just believe did. Nonetheless if they hear it at all it behoves me to explain how such a conversion may occur, and how it may make sense in adopting a broader empathic approach to so called hallucinations.
When Esquirol first coined the term hallucination in the middle of the 19th century, he saw it as a form of madness (delire), yet saw the core feature of a hallucination as an involuntary creative act of memory and relatedness the person has with themselves and the world. Falret thought the same. This is not far from defining it as an inner speech act held stubbornly to come from an external agency. Now the matter of hallucination being involuntary renders the hallucination no different to bone fide stimuli on one hand (I cannot easily filter out the sounds of those ambient noises that involuntarily enter my ears), and bone fide thoughts on the other. No one can claim to be the deliberate interior generator of all thoughts that enters one’s mind. The best we can do is manage thoughts after they arrive, this being the outcome of choice and a dialectic within the self and between the self and others. Inescapability from the thoughts that pop into our mind finds its analogue in the inescapability of the auditory hallucinations that enters our inner perceptual world. The fact none of us is truly the first maker of our own thoughts finds its analogue in the voice as being heard as the “other”. All that is left is to lie to oneself and disavow ownership.
Let us imagine the following three cases, each of which I’ll argue are a continuance upon a spectrum.
Imagine I was raped, neglected, and otherwise mistreated. From this and for various psychodynamic reasons I come to believe I am worthless, unloved and unlovable. Additionally, I have temptation to kill myself. I might look upon the world and believe it to be a human jungle, as Tennyson said, “red in tooth and claw”. I am always on edge that someone may target me for exploitation. Is my lot an unhappy one? Surely yes. Is this the stuff of medicine? That’s debatable. Ought this be the stuff of the state to reengineer me and force its normative demands upon me, that I be made happy? Surely not. If happiness is the goal and the forced treatment makes the patient even unhappier and disempowered, the treatment itself is incoherent. The psychiatrist is incoherent, perhaps psychotic.
Now let’s step it up. Imagine that sometimes when especially distressed, I hear a voice telling me I’m worthless or to kill myself. All the memories of what happened or might have happened flood in at once, along with my relatedness to them. That is to say all those metaphorical voices from my present and all the memories of what others might have told me in the past, or what they were “telling me” when I interpret their behaviour, that is to say what they told me with words and also “told me” with deeds, all flooding into the interpretation of present experience. All the angst and the anxiety of the moment approach a crescendo of phenomenological alchemy where emotion and thought creates a new form. It transmutes into the form of a heard voice.
At such times the psychiatrist, in their drive to superficially classify first and ask deep questions later, may say I am experiencing a “pseudo-hallucination”. This is a most incoherent term of art. What I am experiencing, a perception lacking an objective material source of stimulus, this is a hallucination by definition. There is nothing “pseudo” about it. We can forgive the psychiatrist. Or at least we can understand their motives. The term pseudo-hallucination is not a diagnosis of a symptom. It is goal based to differentiate a particular class of patient from another (vide infra). The whole political exercise of diagnosis and management need hang together to a pragmatic end. With pseudo-hallucinations, when they settle, the patient often realises the voice is a product of their own mind (but not always). In its transience, we justify our calling it “pseudo…”. As before, we smuggle into our evaluation of the voice the sine qua non of a delusion (i.e. belief about a proposition). At the time they hear it they believe it is not inner dialogue.
But it gets worse. We also conflate the concept of “belief about” with the concept of “insight”. Insight basically means whether the patient is aware their psychopathology is psychopathology, whether they realise their mental illness is illness. Insight is a euphemism for submission to psychiatric opinion, i.e., when I say you are deluded or there is no external voice and you disagree, you lack insight. You see all these terms of art are different facets of the same thing that hangs all the psychoses together, i.e., insight. If there was no disagreement about your belief, we could not diagnose it as delusion. If we did not disagree about source of the voice, if you believed the voice was from your mind and cast it off as annoying like tinnitus, then the hallucination has no power to diagnose psychosis. Insight (i.e. disagreement) is always the dynamic at play. The whole drama hinges on a power over the authority to say what is and ought to be.
Returning to the example; Imagine you see me months or years later, only now the voice is with me more frequently. It’s no longer restricted to times of high emotion and acute stressors. No longer is it called a pseudo-hallucination. Now it is rebranded as a chronic auditory hallucination, and I have been rebranded a chronic schizophrenic. Now I always refuse to countenance the notion that the voice is a product of my own mind. I may converse with the “voices” often, being observed to “respond to non-apparent stimuli”. Often the voices distress me. I always refuse to admit that I am the alchemist in the transmutation of thought, of memory and of affect charged inner speech into auditory perception. It is me but I deny it. So what? In what sense is this disavowal of responsibility and personal agency necessarily and essentially pathological? Why does it demand a response by the state to fix me? If I ask you to think of a number between one and ten and the number six enters your mind, did you choose that particular number before its arrival? Insomuch as no one can claim to be the architect of each and every one of their own mental experiences in the world, and no one can claim to be the architect of each and every thought that enters their mind, no one can claim that at least some disavowal of being the architect of mental phenomena necessarily corresponds to a fact of the world and human experience. When the number 6 enters my mind it is from me yet not from me. All I can say is that I am responsible for it. The schizophrenic denies responsibility. So what?
Indeed, many externalize responsibility of what one does with mental phenomena entering the mind. This is the stuff of all the psychotherapies. Do you feel angry and say someone “made” you angry? But how did they “make” you angry? You say the anger then came from them as an act of their creation. But it is your anger. The schizophrenic says they hear a voice made elsewhere by some other. But it is their thought heard as voice. Both are disavowing the true source. Both are true and not true. Might you not conclude from the lack of warmth and false politeness and obstructions from some officious office bureaucrat that the state is indifferent to you and you are worthless to them? You probably are. Or they may even be passive aggressive or hostile, which is to say they are metaphorically “telling” you they don’t like you though they did not say so with words that you hear. What if this interpretation of social life is, as an act of alchemy, heard audibly as coming from the other? And what if the presence, politically speaking, of the other is always there in a sense as a valid symbolic interpretation of the modern world. Though no one is standing before you in your apartment at the time you hear the world speak to you, the world still spins. Its aggression never rests. It and agents within it are always there as a perceived spirit of intentionality, a mood, a symbolic representation of deeper themes and agendas. Once again so what? Some people think in metaphors of what people say without saying. They are sane. Some feel/emote in metaphors of relation. Their gut tenses in an infra cerebral thinking about the tensions of the world and what they think the world is telling them, and what they are telling themselves. They are sane. Some people hear the unsaid. They are diagnosed as insane. Why is this alchemy to congeal meaning into voice not permitted to fall within the bounds of what a human is permitted to be without molestations upon liberty?
Normality in abnormality.
Finally, hearing voices is not statistically normative. This is obvious. Yet looking cross culturally and across the lifespan (especially the youth), voices are much more common than often assumed. Before Esquirols medicalization and the march towards the therapeutic state, hearing voices was not always and universally thought abnormal. It wasn’t even always thought to be demonic possession (psychiatry likes to think it saved us from the cruel iniquities and folk superstition of the previous age). Often visions and voices were interpreted as eccentric, benign, of symbolic worth and even theological value, or perhaps all of these. Take for example Father Ferropont’s visions in the Brothers Karamazov. It is simply a myth of historiography and psychiatric propaganda that the disease symptom/sign of the hallucination was always a problem to be treated. It was and is instead a normal variant of human experience reformulated as disease in the therapeutic state. Even today in many parts of the world hearing voices is often very common and perfectly appropriate. Pick any group of what we may call pre-modern peoples. Try take from them their voices and visions. Go try build a hospital large enough to accommodate those who have them. You will only destroy cultures. Even in our English speaking post-industrial neck of the woods, take yourself into a state of sleep deprivation. Even you might begin to see things or hear things. Or take yourself into a state of existential alienation or loss of connectedness to others. The same may occur. Even in the city drowning in a sea of people we can be lonely. Starving in the midst of plenty, people can invent their own communication with another. Similarly, it is extremely common for otherwise sane mountaineers, shipwreck survivors and the like to have the so called extracampine experiences of another person nearby, even to see or hear them at their side. Even in those who claim to prefer being alone, the revealed preference of the unconscious has the final say. And then there is bereavement and the patently obvious psychological motivations to seeing or hearing the afterglow of the departed loved one. Some may believe these are legitimate visitations of the departed. Maybe they are. Would any reader claim to be able prove this belief false, let alone force the experiencer to heel and disbelieve what their psyche, albeit the unconscious, has chosen to be true to them?
Risk
We have come to the point where those wishing to medicalize beliefs and behaviours invoke the matter of risk, this being essentially much of what much of psychiatric practice is about anyway. The question is “are they a danger to self or others?”. What we are really asking here are two things. The first is what risk the patient poses to society. What do I need to do to perform my function as social engineer and not be blamed by the village in letting a nuisance cause trouble? Secondly managing risk reduces the risk the psychiatrist of will be sued or deregistered. What if the allegedly deluded individual performs an action that harms themselves or others, this action informed by the belief (or “belief about” in the case of voices). Note I did not use the turns of phrase “driven by belief” or “caused by the belief” or “stimulated by the belief” or “made to do”. That would presuppose the absence of free will and deny a capacity for deliberation that ought to be assumed the default state of the adult unless and until proven otherwise. We must labour very hard to escape the language of the ideologies within which we are in peril of being indoctrinated. We must try use language consonant with having made the escape. I have discussed the matter of risk above in the chapter on drug use and in the chapters to follow also on suicide. For now it is enough to repeat, or at least to consider, that what one does as a behavioural response to a belief should not necessarily provoke in others any behavioural response at all, especially not an aggressive or coercive response. Nor ought the behaviour of the patient ever deductively (albeit a posteriori) be the basis of a medical diagnosis because it is troublesome. That is to say, the behaviour does not retroactively make of the belief a pathology.
Hopefully in the sections above I have convinced the reader that the boundary between the normal and delusional belief is not so easily made, and moreover this may reflect taxonomies of belief, i.e. normal vs pathological, sane vs insane, are simply not the case in ontological fact. That is to say, beliefs are beliefs, and that is that. To be sure some beliefs are truth based and some not. Not everyone will have the best representation of reality in their mind. Some people are very right and some people very wrong and everyone disagrees greatly on something with someone somewhere. So what? Apparent falsity as judged by you, me, us, so called science or more often adjudicated by a psychiatrist is not enough to medicalize anyone without medicalizing all sooner or later. We simply have no robust argument of what a delusion is outside of our use of the word to control a kind of deviancy, a euphemism for a critical mass of shared folk prejudice. Let’s look at a couple concrete examples of risk. Someone believes that aqua-phobic aliens are out there and have designs to kill him. Sometimes they even control his movements, and have performed nasty sexual acts upon him, as aliens are often alleged to do. Needless to say there is no material evidence of any of their visitations. Try as one might, arriving at empathic understandability is hard to come by without deeply diving into the symbolic realm. In any case our patient views their phenomena as literal. Now it is a matter of manifest fact that there are many free persons in the world who will express a belief in the existence of aliens, of having seen them, of even having been abused by them. So what? Where do we draw the proverbial line where we dare medicalize such a spectrum of beliefs about the universe, those who may or may not dwell within it and our experience with them? I’ve never met a psychiatrist who can successfully debate this against me without condemning sooner or later half the schizotypicals, pagans, hippies, artists, ascetics, eccentrics, conspiracy theorists, malcontents and misfits down all of human history as insane. Many psychiatrists retrospectively do just that to the extent it seems only those who did not leave any biography can be free from being diagnosed. Every famous person seems to have had some mental illness or another so says one psychiatrist or another. Make no mistake many great people would never have seen the light of day if they fell into the clutches of contemporary psychiatry. Fortunately, I know several psychiatrists from whom such an alien molested patient may be allowed escape unmolested by medication and forced hospitalization should they end their narrative at that. Sadly, this is a minority.
But what if our patient decides one especially persecuted night to risk his life and escape the aliens by swimming out into the center of the lake. Recall the aliens are afraid of water and so swimming away from them is a rational act. To be sure it’s a desperate act, perhaps to escape, perhaps retaliative, perhaps out of spite. Naturally it engenders some risk, and our patient might almost drown or drown for sure. This might even be their intent (just as the ascetic or dissident might self-immolate or starve from hunger for example). Waltzing Matilda he swims out. But there is no denying rationality in the behaviour from the system of their belief. Here the rubber hits the road. I do not know a single psychiatrist who would not see this behaviour in virtue of it being a “risk of harm to self or others”, as somehow recasting the whole belief and phenomenological picture as pathological. Every one of them would use the risk as an excuse to justify saving the patient from the freedom to act according to the belief they have. To say the belief is acceptable if the risk is low and not acceptable if the risk is high is a logically very weak move to make. It appeals only to the drama of the situation to invalidate the acceptability of another’s belief. It is the political control over another’s body and freedom. I can sympathize with the impulse to save another human being. It’s very human. But it is not any more rational than our patient taking the fatal swim. In fact, our patient was the more rational.
We may compare the above with crime. Criminal belief is only actionable if the consequent is a criminal act, a concrete behaviour. Of course, one can imagine an omniscient celestial judge disciplining us for our silent rages, lusts and that which we covet without fair and moral acquisition. That might be the way God judges thought crimes. It is for God to be God. Yet in the fallen world of fallen man one cannot be charged with the crime of a mental representation of a crime, such as fantasizing about robbing a bank. Only from the behavioural act of conspiracy to rob the bank with material evidence of conspiracy (not claims of intent or disclosure of fantasy), or only in the act of robbing of the bank as such, might we be able limit an individual’s liberty. And the prior fantasizing of the crime is not made criminal after the fact of the crime as an additional charge. Even my positing such a word play of un-actioned “criminal belief” is to illustrate a point. Criminality in this case being a metaphor for the thoughts of one with a poor character (or rich and very human imagination), thought cannot be crime. More of this in the penultimate chapter. But when we say that the person carries a thought that if carried out would be a crime, there is some conceptual homology between thought and behaviour, the picture in the mind (the fantasy of the criminal act) being the immoral representation of the immoral act (the crime itself).
So far, we have arrived at an agreement. The thought of a crime will not land you in prison. The behaviour of the crime will. It is worse for psychosis than with crime, and the trap is bipartite. The first horn is the intolerance we might have of the thought itself. Often simply holding the suspect belief can be fertile grounds for being placed under state control. Given such control a) flows from diagnosis and the risk of what they might do, along with b) the notion that the patient ought to be saved from the deleterious state of having the aberrant belief itself, the psychotic illness, it c) often follows they are involuntarily treated, this an analogue of criminal punishment . But we have argued above that the psychotic thought cannot be distinguished from any other thought as pathological. We can only say it is the thought or belief held by a non-criminal social deviant. So what? The second horn upon which the individual might have their liberty impaled is the behaviour. Yet how does behaviour placing self or others at risk somehow alter the picture in one’s mind to something else? There is no thought behaviour homology as there is with the criminal fantasy. In what sense can it be argued that belief in aliens is permissible only up to the point at which attendant behaviours incur a risk of harm to self or others? And having passed the threshold we say “ah, you can be permitted your belief in aliens only if you do not take the belief so seriously as to live it”. You see if belief is not pathological and suicide is not pathological, placing the two together cannot be pathological. What I have deconstructed cannot be put back together.
To my shame I once told the loved ones of so called delusional patients, “we are saving them from the prison of false beliefs, a prison far more insidious than the deprivation of liberty in a psychiatric hospital and the medications we force upon them” (obviously I’m paraphrasing). Is this so different from the Orwellian idea of thought crime and all the horrors of the worst totalitarian ideology? Isn’t the danger all the greater as it’s carried within the mind of the totalitarian agent with a sincere spirit of benevolence. For me then, as it is now in mainstream psychiatry, the matter of risk of harm to self or others is merely a tool of argument in favour of control, playing upon the language of care and fear. It does not somehow breathe life into lifeless arguments seeking the medicalize beliefs as pathological.
What I am proposing is to drop the sham and pretence of psychiatry as medicine and science. Any intervention to deprive the individual of liberty, to stop them from harming themselves or others, and intervene after such attempts have been made ought to appeal to either acts of criminal legislation (harm to others) or an entirely unscientific un-medicalized state of human affairs with attendant language such as is found in morality, philosophy, religion and the basic folk prejudices of the family and the village. I would neither blame the person who drags the self-described alien abductee from the lake than I would blame the alien abductee themselves for taking the fatal swim. What is to be blamed are those who repeatedly ignore the call of the individual to have their liberty and responsibility restored come what may, be it jail or the grave. From the sentiment and behaviours of a concerned citizen or loved one we ought not to create false sciences, language games and systems of coercive control. Psychiatry continuously and egoistically denies the hue and cry of patients who say they prefer to risk death at the hands of aliens, vampires and the CIA rather than life involving psychiatric hospitals and psychiatric drugs. Such love is hatred in disguise. It denies the individual a respect for who they are.
Again, what is psychosis?
Very early in my career I came to see the only way psychosis could be defined was either in terms of an unjustified undefined common-sense prejudice, i.e. “of course he’s insane” or alternatively in an observation of the use of the word, with criteria and ostensive definitions just props in a ritual. This was when the penny dropped, that the definition of psychosis is entirely bound up in the use of the word. I was a junior doctor then. No one understood me, nor wanted to, and I quickly fell into a troubled silence. Only later did I discover other philosophic voices who might have been sympathetic to my own. Empathic un-understandability may seem like a wonderful tool when we cherry pick unusual or concocted examples such as misplaced postage stamps as nonsense evidence of infidelity, and allow ourselves be persuaded by an argument after we have already settled on the conclusion. Here we have designed our own persuasion, and in persuading others are being sophists in the worse sense of the term. Here all we are appealing to is motivated consensus. It’s not a consensus based on logical inference or agreeing on the material solidity of the world by dashing our collective feet on a stone. It gets worse though for logic, and infinitely worse for psychiatric rules and surveying the phenomenological landscape looking for psychotic signposts. Stones will be stones, though the nature of their solidity of these too were questioned in the formulations of Berkley as made in the third chapter.
Later I discovered a kindred spirit in Wittgenstein, who also spoke of the use of words in language as not having any definite meaning in themselves, the meaning only becoming manifest in the use of the words in a custom of human activity. Were someone to yell “duck” we know what to do, not as a conscious act of interpreting the word, as opposed to an act generated by the hearing of the word and embedded within the context of the event itself. Often the action we take upon hearing the word has no connection with thought at all. Perhaps in language acquisition thought never did sit “meta” to action and context, as the primary driver of language itself was learned custom. Upon hearing the word “duck”, do we look for a duck (the bird) as an ornithologist might? Or do we raise the rifle to shoot as a hunter might? Or take it as a message that the companion has seen a headless duck hanging in the window of a Chinese restaurant? Or do we lower our head to miss the swinging boom as a sailor might when the captain yells “duck”? The word “duck” is an observation, a command, a warning, a suggestion or a celebration and much more and nothing in and of itself divorced from context. It is the simplest of what can become far more complicated examples of what Wittgenstein called language games. We might add to this vast list the custom and terms of art in psychiatric diagnosis in general, and the rituals of constructing the patient as psychotic in particular. A devilishly complex language game, it can take years synchronising language use between masters and apprentice (not only for reason that the psychiatric masters are often inconsistent within and between themselves, technically speaking lacking reliability even with the DSM 5, and logically incoherent also in argument). And between masters and their masters there exist hierarchies of power and legacy contaminants from the history of psychiatry. This formulation of psychosis as language based and contextual also “reframes” emergency department physician’s tendency to label any disruptive and disorganised behaviour as psychotic, and why internal medicine physicians seem not to be able to diagnose idiopathic delirium, having the talent to confuse it with psychotic illness at almost every opportunity. These species of physicians are simply playing a different language game, with different goals (i.e. to dump the patient into the arms of psychiatry). It is not that they misdiagnose delirium or psychosis. They are defining it differently in practice, and only acquiescing to psychiatric opinion out of professional courtesy, not as an act of being corrected to the truth.
Allow me to restate the case to follow in various admittedly pleonastic ways, to further free the reader from being trapped in a false idea of what psychosis is, for we have seen what it cannot be. This repetition is necessary, for I am a very strange stranger with very strange ideas. A few pages of repetition are tiny drops of unlearning against the ocean of the standard view into which one has been indoctrinated. The standard definition of delusion in particular we have seen is not worth the paper it’s printed on. The Jasperian reading is also deeply problematic. He was thinking some sophisticated empathic encounter would bring us to the essence of psychosis in the patient. He was thinking you require some expertise in reaching into the patient with a penetrating phenomenological gaze and finding something there corresponding to the word psychosis, a word object denotation, a something being there and pointing to it the way we might do with a physical pathology, a cancer or kidney stone (or the collection of physical evidence pointing towards a specific behaviour such as a crime).
But you see there is no systematic answer to the question of what is psychosis, no coherent definition that is a priori to what we do with the word, no pointing through the person, as it were, at the essence within them of something psychotic/insane.
Psychosis is the word ascribed to a broad range of psychological phenomena and psychologically informed behaviours of, usually, non-criminal deviancy. None of this is an actual concrete object that the word denotes. The words meaning is diffused out over the whole process of the diagnosis as a goal based practice. Psychosis is not some essentiality in the patient. Nor is it in the point when the psychiatrist arrives at diagnosis, as if it becomes the case in the grasping or understanding a mathematical trruth. The diagnosis is often in the “dyadic” interaction of patient and psychiatrist both. It is their diagnosis, and more so the whole ritual or ceremony, it is also what becomes of the person so diagnosed, its function in the world.
Being psychotic is this and it is this in toto; there is a manifold upon which the construct might have its meaning, i.e. the historical pattern of the use of the word before the current encounter between psychiatrist and patient and how that is shifted and shaped over time. This encounter might be with a different set of players, yet it is similar to the diagnostic ritual of the past, i.e. its shifts are not rapid. There is a technique or custom passed down. There was simple psychosis, Soviet style psychosis (political deviancy), Morel’s degenerate démence précoce, Kraepelin’s dementia praecox, Bleuler’s schizophrenia, ED physician’s psychosis (dramatic behaviour), internists psychosis (overlaps with delirium if not dementia), DSM schizophrenia (neither equivalent with that of Bleuler or Kraepelin) etc. All of these were or are “true”. They are just the settings for different language games. Then in the encounter at hand in 2019, the current game at play, it is what the patient says, what the psychiatrist asks, what the psychiatrist proclaims is the case and how the patient is treated, fitting the present encounter to those of the past use of custom. Or it is like a secular marriage (I say secular as the analogy only succeeds if removing the sacramental mystery). The celebrant does not discover the couple to be married. Neither are they married simply by the proclamation of the celebrant, or in the celebrant coming to a point of knowing they are married. They are married by partaking in the ritual and it’s meaning to the wider world. The meaning of a word is in its use. Psychiatry is a socializing/de-socializing/re-socialising ritual.
In summary, the rule or definition comes as an explanation for what we do, which is in practice to medicalize a social deviancy of a particular kind. It is as if we are saying we agree about delusions when we encounter them, and now find need to discover the essence of them by the invention of a definition/rule to justify what we do. We all agree you are crazy. Now let us decide why we agree. When combined with the question of liberty, this is the very definition of a show trial, far removed from a phenomenological study. And this a posteriori definition is ultimately empty without recourse to explaining it by way of the examples which are the very custom of its use. It is then made circular, the arc of the circle with the thinnest edge being the definition, as the definition or rule doesn’t have any strength of its own despite its pretentions. Furthermore, having been divested of the logical strength of the definition/rule, we needn’t have any faith in our grasp of it as pointing us towards something. We think we have a mental hold on something in our definition. But not only is the definition obviously lacking, it can never be proven true. It cannot be shown to point towards itself, let alone something beyond itself to which it is said to represent. And neither can the phenomenological enterprise. What if we all agree 100 patients are delusional (or not) according to our ostensibly shared use of the Jasperian process of empathic understandability? And then we start disagreeing on the next patient. What if you start saying you can empathise with patient 101 and I say I cannot? Curiously we both think we have been using the same process all along with the first one hundred. We both swear we have been following the same rule. Now our disagreement at the one hundredth and xth case might prove that one of us has lost our way, that one of our phenomenological powers have dulled. Yet in a) the fact of our certainty to have both all along been following the same process in patient 1-100 and b) the emergent fact of our disagreement with patient 101, we find c) instead that we were not following the same rule all along, or any rule at all. What we were following was not as solid as we thought. It was a dance upon air, where we each stood on one another’s feet. We just had mutual adherence to a custom, the mutuality of which has been revealed to be imperfect. Now the mutuality is gone. So just who of our first one hundred patients were delusional? Were any? What does it even mean? To the young and budding psychiatrist who might ask me what psychosis is I cannot give them the psychiatric definition and keep a straight face. All I could say is go and sit in the interview room. See the ritual. Calibrate yourself to the ritual. And one day you can take the interviewers seat and partake in the ritual yourself. And then you will see that psychiatric diagnosis is not something you do as in discovering. It is something that is doing itself. A psychiatric diagnosis is a “mastery of technique” as to its use with a goal in mind. Pragmatism rearing its ugly head again. But we continue dancing upon air, convinced it is solid. Idolatry!
Don’t misunderstand me. I do believe in objective truths. Neither am I denying the reality of “madness”. Though born into the postmodern condition I’m anti-pragmatist, anti-relativist and a realist of a certain qualified kind. People with certain deviant behaviours and thoughts certainly do exist. They will say mad things and do mad things. They might annoy people, embarrass family and even place themselves in grave danger. They might not flourish in life, and usually don’t without a substantial buttressing from the family or the state, where the latter sadly very often come to replace the former in the states relentless war against marriage, family and community. Nevertheless these mad persons do not easily or at all fit into the infractions upon sections of criminal code legislation, begging for some other options for micro/macro social engineering and control. And so they will find themselves sitting across from the psychiatrist, our secular shaman invested with the power of the upscaled village, a village which seems to want to lose its collective liberty and responsibility. The psychiatrist/shaman will tell the village if the patient is possessed by the demon psychosis, or not. The psychiatrist certainly exists too. As has been made clear the diagnosis ontologically depends on their participation. The language game has already commenced before the patient arrives at the interview room, in the suspicions of the laity, how they seek a place to alienate the individual, to find some other prison in which to place them, in wishing to find someone to explain them, to solve them, the decode them, to change them, to help them, save them, absolve them of responsibility, treat them, restore them to being a comfortably normative object for the state and its various subjects. The complainant laity certainly exist also. How the complainant recognises the customs not to play and whom to call, (e.g. the white coats and not the boys in blue, except the latter as adjuncts), and the ends they seek…all is part of the custom. And when sitting across from the psychiatrist he/she will ask x, the patient will answer y, and the word psychosis or schizophrenia will come to be invoked if necessary for social control and engineering. The attempt to return the person to normative function will begin, with force, with domesticating medications, and with periodic confinement if necessary. That is all psychosis is. No more fruitlessly looking for chemical imbalances or brain shrinkage (these will come after the psychiatric drugs). Just the playing out of the consequences of whatever special deviancy is a la mode by the psychiatric orthodoxy of the time and place. Whether it be hearing voices, believing you are the queen of Sheba, believing you ought to be freed from slavery or having the cognitive dysfunction not to recognise the self-evident correctness of Soviet Socialism, it doesn’t matter. All can be psychosis. So if you wish to enter into the church of psychiatry, then please untie yourselves of the knots your professors have bound into your mind. Please do what you will do shamelessly and with clarity. Be honest to all involved, starting with thyself. You are an agent of the state, a political actor, a complement to the police in minimizing social deviancy. The patient is mad because we agree they are. That sentence is both the beginning and the end of the dialectical show. But should this chapter lead you to feel a sense of doubt with your erstwhile cherished power of discernment of the mad from the normal and what it all means, hallelujah. Let the doubt I have placed in you fester. Let it be like acid dripping onto the untruths of a troubled mind. Doubt and doubt some more. Spread it amongst friends.
Epilogue April 2023
This year is the 50th anniversary of Rosenhan paper discussed at the opening of this chapter. The early 70’s and Rosenhans work marks the end of an era of heroic experimental psychology. Any psychiatrist who has read it and not been drawn into troubled reflection on what it might tell them of themselves lacks the character to be a good therapist. Far worse is the psychiatrist who has never read it.