Monday, 29 August 2016

Delusions and Verisimilitude

What's the one thing everyone knows about delusions? That they're false beliefs. Not so fast. Already we have two problems. First, there is much debate among philosophers about whether they are really beliefs (recently the linguist Dariusz Galasinski has written a fascinating post about whether delusional utterances even always have to be propositional statements).

Additionally, it's not clear that delusions always have to be false. An oft repeated sentiment in psychiatry is that even a true belief ("my wife is cheating on me") could be delusional if held with the right (or, I suppose, wrong) sort of conviction. That idea is usually attributed to Karl Jaspers, but not having read him yet I can't confirm. I have also seen it attributed to Lacan, but I don't recall coming across it when I read his weird, poetic Seminar on the Psychoses. Perhaps someone could point me to the source.

I am intrigued by the possibility that a true statement could be a delusion. It seems superficially rather a contradiction in terms, after all "delusional" is a rhetorical way of describing something as patently false. Nonetheless it makes some sense. It seems possible to have a pathological conviction about something true. Imagine correctly insisting that it was raining outside when you had no means of knowing it were so. Healthy assertion about most things contains withing itself the germ of the possibility that the person asserting could be wrong.

It seems then that we can be delusionally correct in certain circumstances. Is there also another way delusions could be true? Could they be, as I think some therapists would like to suggest, a form of communication about reality? Could it be that delusions, even quite wild ones ("I am having my mind read by the president"), have some element of truth to them?

Some people think so. For example, one therapeutic approach suggests finding the relate-able component of any delusional utterance and focusing on that. A supervisor recently told me that she was once confronted by a patient yelling "we're at war!" and responded by saying "you must be very frightened". I can't resist the detail that the patient turned out to be flatly correct (it was 2003 and she was referring to the outbreak of the Iraq war), but my supervisor's approach was a good one I think. When someone says something to you that is on-the-face-of-it at odds with your understanding of reality, it seems more communicatively cooperative to find the part that both of you make sense of. "You think other people can read your mind? Well that must feel terrifying and very exposing."

Such an approach sometimes gets packaged up as a form of relativism or pluralism, the idea being that there is no such thing as one truth. That might feel quite comfortable for people of a certain philosophical persuasion; if you are a pluralist or post-modernist about truth, then you needn't be troubled by the idea that any given statement is false.

Image result for this is my truth tell me yours
Do we have to have different truths?

Unfortunately I like the therapeutic stance but not the philosophical posture. I have come to belief in truth. By this I just mean that I think that some states of affairs are the case, while others are not. What is more, I think most people secretly agree. If you jump off a bridge (all other things being equal), you'll end up moving downwards. If there were nothing that were true it would be supremely weird that we managed as a species to agree over so many things.

So what do we do? Can we still say, following sympathetic therapists, that delusions have some truth to them? I think we can. Beyond the idea that some statements are true and others false, there is the idea in philosophy of science, that any given statement can be more or less true; that is, have more or less verisimilitude. Take these two statements: 1. "There is no such thing as schizophrenia" 2. "Schizophrenia is a real illness". They seem mutually contradictory, as though they couldn't both be true. They certainly cause a lot of argument. Regular readers of this blog might already have a view about which is right and which is wrong.

I think such arguments usually arise because the people apt to make one of those statements often think they are saying something that could be simply true or false. This is a mistake. One of the reasons such contradictory statements can exist (and it is surely one of the reasons that relativism about truth is such a respectable position in some circles) is that so many of the claims made in this domain are impossibly under-specified as truth-assertions. That is to say, my example statements 1 and 2 use such loosely understood words ("schizophrenia", "real") that we cannot gauge their truth value without interrogating some hypothetical speaker to get further qualification.  For what it's worth I think both statements have some verisimilitude. I go back and forth about which one I think has more truth than the other, but they are both getting at something basically correct.

How does all this help us with delusions? Delusions are like the statements studied by philosophers of science. They are often (though not always) statements about how the world is. If this were not so we might not bother calling them delusions to begin with. People falsely claim they are being watched; that they are of unusually superior ability; that they are infected with some fatal disease. It seems right to be aware that such beliefs are are often untrue. At least the headline assertion is often false. However delusions are usually complex and under-specified statements. Minimally, a person who makes an outlandish claim about the world is also making a less ridiculous one about what it is like to be them at that moment. Broadening our view somewhat, they might be making a quasi metaphorical statement about some aspect of their environment. I will not be saying anything radically new if I suggest that sometimes, delusions are informative in surprising ways.

Therapeutically this is nothing new. Sympathetic listeners have long held that delusions contain something true. Confronted with an uncomfortable contradiction between a patient's beliefs and their own, many people's instinct seems to be to assert the possibility of a plurality of truths. People of some philosophical persuasions (self included) find this too wishy-washy. Perhaps verisimilitude can help us square the circle. 

Monday, 15 August 2016

Trump: A psychological fiction

Nobody predicted it. A chronic narcissist they said. Mentally unstable. Not fit for office. But 2016 was that sort of year. The unthinkable had happened time and again. In retrospect the rise of Donald Trump to the presidency seems inevitable. Already the succession of events seems pre-destined; a global economic downturn, combined with the shift of manufacturing jobs overseas, guts the white American working class financially, at the same time as the rise of a triumphant cultural liberalism aliented them socially. Trump was able to ride to power on a double wave of anger. The story seems designed for school history books.

It took no time at all for Trump to look seriously out of his depth. What had looked like confident bluster for most of the previous year (and had so pleased that section of the population that had voted for him after years of feeling sick at being condescended to by the "liberal elite") started to lose its sheen even for the Donald's most ardent fans. It was one thing for Trump to swagger onto one of his golf courses in Scotland during the UK's EU referendum. It was quite another to watch him garble his way through his first joint press conference with the proficient Theresa May. For the first time in living memory a US president came second fiddle to a UK Prime Minister. Worse, for former Trump supporters, this was a woman!

Again and again Trump looked foolish. His gaffes piled up; mixing up North and South Korea during his  inauguration address, appearing to think Francois Hollande was the Canadian premier, and of course the unforgettable backtracking on the great Mexico-US border wall as it transpired almost immediately that such a project was utterly unfeasible. Never in history had a president looked so hopeless so quickly after taking office. 

But the really unpredictable part came next in mid 2017. Rumours began to circulate that the joint chiefs of staff were plotting to find some way of dealing with Trump. Not unseating him (a straight coup would have been too de-stabilising for America), but subtly moving to de facto rule by military until the 2020 general election rolled around. Despite America's historical love of democracy, there was a quiet sense that most of the population would have supported such a move. Americans may have been sick of being governed by politics-as-usual career politicians, but they had no wish to see the country driven to complete destruction by someone as nasty and stupid as the president.

Trump's bluster began to falter. For a man with a historical lack of any apparent humility (or capacity for self reflection) he started to seem far quieter. Interviewers noticed a calmer quality. He was famously photographed leaving a briefing in the Oval Office with tears in his eyes. Suddenly Trump's mental health was in question again; tabloids ran crass stories about him losing it; buckling under pressure.

And then the game changing press conference on the White House lawn in September, reading tearfully, but with unprecedented dignity from notes on a lectern. "Fellow Americans, I have a burden I wish to share with you today; the burden of a man who has battled all his life with crippling shame and self disgust." The journalists were aghast. Was this a bizarre trick? A resignation? Had Trump finally gone mad?

He continued:
During my campaign a lot of people threw a lot of diagnoses at me, a lot of hateful terms. That hurt, but I did what I have learned to always do, to shrug it off and roll on. I knew I could ignore the haters, even feed off them. I had never known failure before, not real failure, so I rolled on, thinking I could just keep my head above water. But in my months as president I have learned something profound; something which has changed me more than I can hope to convey to you. Those wannabe doctors throwing diagnoses at me? Well, painful though it was to admit it, I have come to see they were right. Here's what the doctors say they mean by Narcissistic Personality Disorder:
Trump pulled out a piece of paper and read out the DSM-5 criteria for NPD. He laughed at each item on the list, with the Washington press pack (nervously at first) joining in too, sharing with him this unprecedented self-disclosure:

  • Grandiosity with expectations of superior treatment from others
  • Fixated on fantasies of power, success, intelligence, attractiveness, etc.
  • Self-perception of being unique, superior and associated with high-status people and institutions
  • Needing constant admiration from others
  • Sense of entitlement to special treatment and to obedience from others
  • Exploitative of others to achieve personal gain
  • Unwilling to empathize with others' feelings, wishes, or needs
  • Intensely jealous of others and the belief that others are equally jealous of them
  • Pompous and arrogant demeanor
Sounds like me right? Well, at least it sounds like the me of last year, and the me of my entire life up to now. I've been that guy everyone calls 'arrogant'. I've been the pompous entitled guy who bullies and intimidates to get what he wants. But I have to tell you, there is another side to all this that the psychiatry textbooks don't play up; the feeling of vulnerability, shame and goddam self hatred underneath it all!
He was getting tearful again, and across America, so were millions of others too. Blue collar workers who had voted Trump to stick it to the liberal elite; New York intellectuals who had hated Trump and everything he stood for. Blacks. Whites. Latinos. All across the country, people united in shared emotion at the disclosure suddenly being made by the most powerful man on the planet. Trump went on and described the intense feelings of loneliness and shame he had experienced all his life, and which he had protected himself from using a defensive shield of confidence and grandiosity.

What Trump did that day changed America's understanding of mental health, and of Narcissistic Personality, forever. Trump made a radical shift toward collective governmental decision making, openly acknowledging his own limitations; "now I have been open about how I used narcissism to defend myself, I don't have to hide my own lack of knowledge or experience; I can learn! It's liberating, really."  Bullying bosses across rethought their behaviour as the president role-modelled a strong but fallible leader. Books appeared describing that hidden underbelly of narcissism; the fear and insecurity it hides. The American Psychiatric Association revised the DSM to more strongly emphasise that "true self" core underneath the defence. And slowly the term came to have a less insulting ring as the population at large stopped associating it with brashness and arrogance, and held in mind instead that fragile, frightened person underneath to who we can all relate.

As I write this, in 2018 Trump's approval ratings are middling, but there is an unprecedented sense of warmth and respect for someone who, having brought the country to the brink of crisis, managed to weather his own psychic storm to rapidly. Americans have weathered that storm with him, and there is a feeling that somehow leadership has been changed forever. 

Saturday, 6 August 2016

"None of that was real": Folk metaphysics and psychopathology

A brief selection from Irvin Yalom's latest book of psychotherapy vignettes: A newly qualified clinical psychologist (Helena) seeks psychotherapy with Yalom after realising that a recently deceased friend and travelling partner would have met criteria for bipolar disorder. Reflecting on their exhilarating travels together, Yalom’s patient expresses an unsettling worry:

What I used to consider the peak of my life, the glowing exciting center, the time when I, and he, were most thrillingly alive—none of that was real. (Yalom, 2015. Italics in original).

There is a peculiar sort of folk metaphysics on display in this complaint. Helena has just qualified as a clinician and now reinterprets the behavior of a gloriously energetic friend in terms of illness. Perhaps aspects of the friend’s life do make sense in terms his having of a mood disorder, but the idea of such an illness seems to rob some of his experiences of perceived authenticity. Although it is less tangible a harm than stigma, detention or forcible medication, this sense of lost reality seems to be a profound and damaging alteration in conscious experience.

Here in microcosm we see a hint of how people (even clinicians) think about psychiatric disorder categories. Not real. Not mine. Not me. I feel bad for the clinical psychologist's patients. What an impoverished and concrete way she has of thinking about their experiences.