Reichenau Summer School: Dealing with Uncertainty

In today's post I report on the Summer School in Reichenau  which I had the pleasure to attend on 25th and 26th August 2023. The theme was Belief, meaning, knowledge: how we deal with uncertainty. Delusions was a topic often discussed in the presentations, from philosophical, phenomenological, and clinical perspectives. Organisers of the event were Johannes Rusch, Daniel Nischk, Dorothea Debus, and Thomas Müller.

Rathaus Reichenau (front)

Rathaus Reichenau (courtyard)

The first speaker was Rico Gutschmidt (Konstanz) with a presentation on Mysticism and Delusions. Fundamental uncertainties are limitations of knowledge and experience and three questions arise: (1) Where do we come from? (2) Why there is anything at all rather than nothing? (3) Who are we? Although such questions are not easy to answer or possible to answer they can evoke transformative experiences. Philosophical experiences such as struggling with these questions can be transformative because they change the type of people we are. They change our attitude towards life. They contribute to the mystery of existence.

Mystical experiences are an extreme form of transformative experiences. They can be induced by substances and meditation and can include a feeling of unity with everything and the loss of the self. People feel like they understand a deeper level of reality that is often ineffable -- cannot be put into words. Such experiences can be both positive and negative, they are often overwhelming. Gutschmidt argued that mystical experiences can be reinterpreted as experiences of the unboundedness of existence.

In a recent study led by Gutschmidt and Nischk several participants were interviewed and their interviews analysed in interpretive phenomenological analysis: it was found that some delusions are very similar to mystical experiences (loss of the self etc.). So these types of delusions can also be interpreted as experiences of the mysteries of existence. In this sense, delusions are not pathological and involve a revelation of a deeper reality (enlightenment); the sense that one is outside time and space and past, present, and future are fused together; and ineffability. Patients describe delusions as meaningful experiences.

The second speaker was Uwe Herwig (Konstanz and Zurich) who presented about Psychedelics: Phenomenology and Psychotherapy. As the talk was in German, I will offer only a very brief summary of its contents. Herwig started with an introduction on psychedelics. Often psychedelic phenomena occur in ritualistic settings. Psychedelics are a group of substances that modify the qualitative nature of the experience. The words "psyche" and "delos" mean "opening the soul". A typical psychedelic substance is Psyllocybin and an atypical one is Ketamine.

Uwe Herwig presenting on psychedelics

Then Herwig provided a brief history of the use of psychedelic drugs in clinical contexts. First therapeutic use of psychedelics occurred in the fifties, mainly for anxiety and depression. New applications have been introduced since 2020, for post-traumatic stress disorder and substance dependency as well as anxiety and depression, with various measures of success. The study by Hendricks et al. (2015), showing that psychedelic use is associated with reduced psychological distress and suicidality, was discussed in some detail, as well as more recent studies. In the last part of the talk, Herwig explored the psychophenomenology and neurobiology of psychedelic treatments, arguing that such treatments work and clinicians need to be prepared to offer them.

On the second day, Philipp Sterzer (Basel) presented a paper on the Functionality of Delusions. He started defining psychosis and its symptoms (delusions and hallucinations) and described the Bayesian approach to explaining psychosis. The key is abnormality in inferential mechanisms: what we perceive is always an active process of inference where we predict what things are like given what we already know. If we fail in our prediction, then there is a prediction error, and that's usually a bad thing. But via prediction errors, we can update our beliefs. Inference is to minimise prediction errors.  

When we have psychotic symptoms, our priors are not precise and the new experience is very salient. So, the story goes, in psychosis we are more guided by the actual stimulus and tend to ignore priors. What does the evidence say? People with delusions are more resistant to visual illusions and their priors are weak. However there is also some evidence that people with hallucinations have strong priors. 

Philipp Sterzer and a picture of his book, 
Die Illusion der Vernunft

So it would seem that there are two separate mechanisms:

Weak prior -> Aberrant salience demands explanation -> Emergence of delusions (bottom-up)

Strong prior -> Sensory signals interpreted in accordance to priors  -> Persistence of delusions and emergence of hallucinations (top-down)

But a more complex hierarchical model solves the apparent paradox:

Weak low-level priors -> Aberrant Salience demands explanation -> Emergence of delusions

Strong high-level priors -> Sensory signals interpreted in accordance with priors ->  Persistence of delusions and emergence of hallucinations.

Studies on perceptual ambiguity and on perceptual uncertainty conducted in Sterzer's lab show that weak priors can be at the origins of both delusions and hallucinations. Schizophrenia patients use sensory evidence more than controls to disambiguate stimuli. In sum, what we have in psychosis is lower perceptual history biases and higher sensitivity to disambiguating evidence. In this framework, delusions are a compensatory mechanism used to minimise prediction errors. And the people most likely to adopt delusional beliefs are those whose brains create more ambiguity. 

Susanna Burri (Kostanz) was the last speaker of the day and the Summer School, and her talk was on Final (and Other) Goodbyes. She asked what a good dying process looks like: what type of death should we hope for? Two options are the Sudden Exit (e.g., just drop dead) and the Some Advance Notice (e.g., knowing you will die in two weeks).

Susanna Burri discussing good ways to die

Occasions for goodbyes include when we leave people behind (in a valued relationship); when we leave places we are attached to, or other non-persons; when there is no increased physical distance but when there is increased psychological distance (e.g., the relationship changes). A goodbye is about anticipating and acknowledging a loss. Burri offers a definition of saying goodbye:

Goodbye: to say goodbye is to openly acknowledge and reflect on the fact that a valued relationship or set-up is about to come to an end or change significantly.

What is bad about goodbyes: (1) goodbyes are meaningless performances, (2) they are awkward and delay things for those leaving, (3) they detract from the fun and they interrupt the flow for those staying, (4) they are unpleasant because they are an ending. What is good about goodbyes: (1) goodbyes are respectful and helps those left behind to adjust their expectations, and (2) they help people prepare for the ending which will make grief easier later. Preparing for a loss means interpreting it and helps us determine what the value of thing or person you are losing is. As a result, saying goodbye provides orientation: it prevents feeling lonely and drifting. Goodbyes also help showing appreciation for something that was valued.

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The Summer School was a really great opportunity to interact with people with different backgrounds and enabled participants to discuss all the key themes in detail and in a relaxed and friendly atmosphere.