Tuesday 17 June 2014

Are Delusions Acceptances?

Keith Frankish
If psychotic patients did not tell us, would we guess what their delusions were? We might see that a patient was depressed, withdrawn, self-neglecting, and so on, but would it occur to us that they thought they were dead, as Cotard patients do? It is doubtful. Deluded patients are firmly attached to their delusions, but the attachment manifests itself most clearly at the verbal level, in what they say and how they argue, and may not show up clearly in their nonverbal behaviour. Most Cotard patients do not (as one early case did) arrange their own funeral.

Why is this? The answer, I think, is that delusion is an attitude closely bound up with language -- an attitude sometimes called ‘acceptance’. To accept a proposition, in this sense, is to commit oneself to arguing for it, defending it, using in reasoning, and acting upon it. This is the attitude a scientist takes to a hypothesis, a lawyer to the claim that their client is innocent, a politician to a policy. It is a sort of intellectual commitment, which is active, reflective, and conscious. (For more on acceptance and a detailed presentation of the case for thinking that delusions are acceptances, see this paper.)

If delusions are acceptances, then several things follow. I shall mention three. First, delusions are active. Accepting a proposition involves making and executing a commitment to a certain pattern of argumentation and reasoning. Thus, deluded patients are actively engaging with their situation rather than just passively responding to it.

Second, delusion is motivated. We accept propositions because doing so answers some need or goal (not necessarily a conscious one). This might be simply the goal of accepting truths, but it could be pragmatic, as in the case of the lawyer. Thus, a new question arises about delusions: What need or goal does the formation of a delusion address? It could be epistemic; maybe the patient is just trying to make sense of their distorted experiences. But a delusion might serve other psychological needs, especially emotional ones. For example, it might be a comfort to have a simple framework for representing what is happening to one, however bizarre.

Third, delusions have limited behavioural influence. Acceptance does influence nonverbal behaviour -- the commitment extends to acting upon the accepted proposition -- but this influence is often limited. An acceptance may be deliberately restricted in scope (the lawyer accepts her client’s innocence for professional purposes only), and even if it isn’t, it won’t automatically guide routine behaviour. Acting upon an acceptance requires paying attention to what one is doing and deliberately regulating one’s behaviour to bring it in line with the proposition accepted. Moreover, even if one realizes that an acceptance dictates a certain action, one’s desire to adhere to it might be overridden by other desires. (Think of the effort involved in adhering to a moral principle one has accepted.) Thus, delusions will only influence behaviour that is under reflective control and may influence that only in a patchy way. This does not mean that a patient’s unreflective behaviour will be normal, of course. But it will manifest their distress in a raw uninterpreted form, rather than one constrained to reflect the pattern imposed by their delusion.

The idea that delusions are acceptances has been discussed before on this blog, but it has not received a lot of attention, perhaps because the literature on acceptance is not itself widely known. I hope this will change and that the hypothesis will be explored and evaluated in clinical contexts.


  1. Very persuasive. 2 comments. 1. To what extent can this analysis be extended to non-pathological delusions? I have in mind commonly accepted yet arguably false beliefs about one's own mind - libertarian free will, certain assumptions about rationality, transparency of the mind, unity and persistence of the self, etc.? It seems like such self conceptions can be interpreted as acceptances motivated by social benefits, eg, it's easier t coordinate with people who have similar or complementary self conceptions. 2. This is related to Pawel's point. Delusions don't seem like deliberate, voluntary, consciously adopted policies - not a person-level phenomenon. But, as Pawel notes, acceptance seems to have such connotations. For this reason I've been toying with a different metaphor: delusions as software sub personal neural processes decide to "run". Like software, truth isn't relevant to evaluating delusions; what matters are the costs and benefits of what they get us to do...

  2. Interesting perspective. But why would *all* delusions be acceptances? Is this assumption of homogeneity of delusions warranted? The term "acceptance" implies a voluntary component to me and this seems at odds with the fact that delusions caused by various medical conditions exist. In what sense is the delusion still (entirely) an acceptance in these cases? Especially if there is perpetual resistance/conflict present during persistent delusions?

  3. Thanks to Tad and Pawel for their excellent questions! Some quick responses.

    First, let me add something that I should have stressed in the post. In saying that delusions are acceptances, I don't mean that nothing else unusual is occurring in delusional patients. I assume there will typically be some pathology, perhaps involving distorted perceptual processing or a disorder of affect, which causes serious distress and disorientation. But (I claim) this raw distress on its own is not delusion and does not come with a delusional content attached. The delusion arises when the patient accepts a particular interpretation of their distress and its cause. So it would be more accurate to say that delusions have an acceptance component. In that sense, this is a two-factor theory.

    On homogeneity: I defend the acceptance account for topic-specific (monothematic) delusions, such as Cotard or Capgras. However, I'm inclined to think it can be extended more widely. Being cautious, I'd say that in so far as delusions have a belief-like component, that component is acceptance. Since I think that all conscious belief is a form of acceptance, this is a fairly weak claim, but it does rule out completely passive, nonconscious delusion.

    On the extension to non-pathological delusions/unwarranted beliefs: Yes, absolutely. I think that all conscious, truth-directed propositional attitudes are acceptances of one kind or another, some epistemically motivated, some pragmatically motivated, and some with mixed motivation. (Some of these we would call ‘beliefs’, some not.) I sketch a taxonomy of acceptances in my 2004 book.

    On voluntariness: Acceptance is personal-level and active, so I am committed to the view that delusions have a component of that kind. But there are some qualifications to add, which may partially accommodate the points made by Pawel and Tad. (1) As mentioned above, there will also be an involuntary component to delusion. (2) To say that a patient accepts a certain interpretation of their situation isn’t to say that they welcome it. They may find the conclusion distressing, but feel they have to acknowledge it all the same. (3) I assume that personal-level actions are constitutively dependent on subpersonal processes, so in principle the story could be told entirely in subpersonal terms. The picture I have is one levels of description, like Dennett’s. So my view could be expressed as the view that delusion formation is a process that has a personal-level description as well as a subpersonal one -- in contrast to nonintentional responses.

  4. It seems to me that not only not all delusions are equal, and that all similar delusions may not be arrived at in the same manner. This means adhering to equifinality. Would this call for a delusion-specific acceptance taxonomy, or can this be indicated in some other way? It seems important.

    Perhaps this will sound rather exotic, but can we imagine a case of a severed corpus callosum where the patient 'inherits' the delusion and thus cannot consciously access this belief/acceptance, yet will act upon it? Various forms of hemispatial neglect would possibly pose similar problems. The idea here is to come up with cases that put any crucial aspects of acceptance and the delusion in question at odds.

    A similarly confusing case may arise in the case of a child whose buzzing, blooming confusion phase leads to or coincides with the incorporation of some delusion. Here we could wonder if the formation of the delusion, when pre-dating many significant developmental phases, might violate the idea of acceptance in any way, as they would require far more conscious agency than such a young child would have. Would it not be system 1's (per dual process theory) automaticity that would lead a habituated state, perhaps in a sense that violates criteria of acceptance, such as the active engagement component?

    Is the phantom limb an interesting case? And since the brain takes multi-level cues from the sensory system to build one's model of reality on the fly, is it sensible to look at body transfers illusions as well? It seems to be these can be cases of the aforementioned conflict that persists as the delusion persists. Could it be that in some cases at least, rather than just acceptance, there is darwinian struggle occurring, where acceptance or non-acceptance may or may not be the final result - something in between?

    Delusions as well as acceptances seem to have several important components and that a few are necessary but there might be a taxonomy of components that satisfy sufficiency and whose heterogeneity may make delusions difficult to model in a clear and clean way. Are (all aspects of) acceptances necessary for delusions?

  5. As a psychologist rather than a philosopher I’m new to this debate. I hadn't come across the idea of ‘acceptances’ before, for example, and it seems a useful one.

    I’m also struck by parallels with three debates within psychology.

    The first is the issue of the extent to which delusions can be understood in the same way as other beliefs. Some recent cognitive models suggest that they are essentially the same, for example Tony Morrison’s:

    ‘A benign lump in one’s skin may be misinterpreted as a sign of cancer by a hypochondriacal patient, but the misinterpretation of the same stimuli as being a transmitter or homing device installed by the secret police would be more likely to result in a patient being regarded as psychotic.’ (http://feltoninstitute.org/approach/morrisonsinterpretationofintrusions.pdf)

    The second is the issue of equifiniality, which to me seems key. I’ve edited an account of the psychology of psychosis intended for a public audience (https://twitter.com/AnneCooke14/status/489872427644903424) which states, for example: ‘It’s important to bear in mind that the ‘causes’ of complex human thoughts and feelings are different from the ‘causes’ of simpler things like chemical reactions. We need to be careful in the way we think here. In particular, although there are commonalities, different combinations of causes are likely to be relevant for different people, and to interact with each other’.

    The third is the issue of the extent to which different accounts reflect different levels of explanation rather than being incompatible. For example, the same document states that:

    ‘An enormous range of things have been proposed as possible causes of psychotic experiences. As every thought is both a brain-based event and a human experience, it can be impossible to separate out different types of causes. It can be helpful to think in terms of ‘levels of explanation’ rather than causes. For example, a thought can be explained in terms of its brain chemistry (which chemicals are involved?), its psychology (e.g. do people have different ‘thinking styles’ in different moods?) or its social context (e.g. what has happened to which the thought is a reaction?). An explanation might link these levels but one does not ‘cause’ the other any more than, say, the wiring of a television ‘causes’ the plot of EastEnders. We need to understand many different things in order to explain why people spend hours watching a flickering screen’.

    I’m aware that some of this probably seems quite basic to philosophers. However I’m glad that via blogs, Twitter and so on we (the different disciplines) seem to be coming out of our silos a bit and talking to each other more.

  6. RATIONAL, adj. Devoid of all delusions save those of observation, experience and reflection. (Ambrose Bierce)

  7. Hi, Keith,

    I was recently alerted to the existence of your post. Thank you for writing it! I'm very much on board with the delusion-as-acceptance thesis.

    Despite being on board, I want to press you on a point of disagreement. I do not think that delusions are necessarily active or motivated. But I do not think that this means that delusions are not acceptances, because I do not think that acceptances are necessarily active and motivated!

    I know that you hold otherwise, and I am curious why you think that motivation and action are essential to acceptance. There's still a lot of potential refinement that can be done to the concept of acceptance, so I'd like to know the reason for constructing it this particular way. I prefer to think that acceptances can be active and motivated. Many are. But not all.

    My reason for thinking that volition and action are separable from acceptance is this: there is a difference between adopting a premising policy and having a premissing policy. Adopting a policy is an action, and so it might well be volitional. But having a policy is to be in a functional or dispositional state; it's not something that one does, either volitionally or non-volitionally, either actively or passively. Sometimes authors who write about acceptance equivocate on whether acceptance is a mental state or a mental action (not you, I should note!). Once we separate these two notions, I don't see why the state must be essentially linked to any particular method of formation.

    Suppose I wake up one morning to find that I have a personal policy of reasoning from a certain premise. I didn't volitionally decide to adopt this policy. It's just there, through some quirk of mind or knock on the head in the middle of the night. I am dispositionally indistinguishable from someone who voluntarily decided to adhere to the policy... but I didn't make any decisions to get this way.

    Is this scenario a conceptual possibility for you? Why not think that delusions are like this?

    Perhaps you think that premissing policies require personal-level explanations of their formation because premissing policies are personal-level mental states. If so, why think that this personal-level explanation needs to involve motivated action? Some personal-level explanations of mental life do not invoke motivation. For instance, I like this story: when a person is beset with overwhelming emotion, they straightaway form an acceptance. Overwhelming fear in an approaching dog leads one to accept that the dog is dangerous. Unless I misread what you mean by 'person-level', that could be considered a person-level explanation without motivation. (I guess you could introduce a motivational aspect into this story --- you could say that the person desires to relieve their fear and recognizes that accepting that the dog is dangerous will cause them to run away which will then lessen their fear --- but that explanation seems overintellectualized to me.)


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