Tuesday 14 March 2017

Delusion: Solving for Understanding and ‘Utter Strangeness’

Today's post is by Bill (KWM) Fulford and Tim Thornton. Bill is Fellow of St Catherine’s College, Oxford, and Emeritus Professor of Philosophy and Mental Health, University of Warwick.  Tim is Professor of Philosophy and Mental Health at the University of Central Lancashire.

Bill Fulford

Tim Thornton

What is delusion? Few questions have so vexed philosophers in recent philosophy of psychiatry. An invitation to contribute to Thomas Schramme and Steven Edward’s Handbook of the Philosophy of Medicine (Springer, 2016) gave us a welcome opportunity to review progress.

The philosopher Naomi Eilan characterized the challenge of delusion as solving simultaneously for understanding and for utter strangeness. Karl Jaspers, the great philosopher-psychiatrist of the early twentieth century and founder of modern descriptive psychopathology, would have approved. He famously thought delusions just too strange to be within the reach of empathic understanding - ‘ununderstandable’ he called them.

Contemporary theories, seeking understanding by explication, fall, we think, broadly into two categories concerned with delusions as aberrations on the one hand of beliefs or other either familiar or bespoke propositional attitudes or, on the other, of the grounds of beliefs or other propositional attitudes. The many variations on these theories each offer important insights. None though meets Eilan’s challenge in full: propositional attitude-focused theories solve (in part) for understanding but at the expense of strangeness; grounds-of-belief theories solve (in part) for strangeness but at the expense of understanding. It may be time therefor for something new. It may be time we suggested to turn our attention to the agential aspects of delusion.

Agential theories of delusion focus on their prima facie connections with rational agency: the feature of delusions that puts them at the heart of the insanity defence. Such theories are promising at several levels. First, they widen the scope of enquiry beyond a particular kind of mental state (eg belief versus imagining) but to the totality of mental states whose interrelations characterize agency. Delusional value judgments, in particular, become natural partners to delusional beliefs.

We think that there is a clinically recognizable local breakdown in that those relations which is not sufficient to take someone outside the space of reasons (a mere machine) but which resists specific understanding because, as Jaspers emphasised, the reasons cannot be shared. Further, just as rationality as a whole resists codification so breakdowns in the space of reasons do too. Recognising delusion is thus a matter for tacit rather than explicit knowledge. This in turn means that agential theories encompass the important but thus far neglected class of non-pathological delusions: delusions that are harmless or indeed positively adaptive in the life of the person concerned. We give examples in our review.

Recent epidemiological studies suggest these and other non-pathological psychotic experiences (such as voice hearing) are commonplace. The widened scope of agential theories means that they also have potential practical impact. For this connects them naturally with such features of contemporary clinical care as whole-person approaches to cognitive-behavioural therapy and co-production of recovery-oriented services.

Much of the work towards agential theories of delusion remains to be done. The philosophical building blocks though are already there: from phenomenology, work on the ‘life world’ provides space for difference (not merely defect); from philosophy of mind, John McDowell’s picture of a shared but uncodifiable ‘space of reasons’ encompasses the twin fact+value nature of delusions; and from philosophical value theory, the concept of dissensus enacts the mutual respect for difference on which effective translation of theory into practice is premised.

An agential approach may finesse Eilan’s joint challenge of solving for understanding and ‘utter strangeness’. The latter, because it views delusions as an unshareable local disruption to the space of reasons. But the former because such disruption can at least be charted and tacitly recognised. Exploration of local disruptions presupposes a background of shared understanding and mutual respect.

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