Prospects and problems for a phenomenological approach to delusions
Authors: Richard Bentall
Journal: World Psychiatry (2015)

In this issue of the journal, Sass and Byrom 1 outline some phenomenological accounts of delusion formation (highlighting experiences which, for simplicity, I will refer to as “altered reality experiences”) and identify some points of contact with the relevant neuroscientific literature. As they freely admit, some of their ideas are speculative, but the general case that researchers should take the work of phenomenologists seriously is well made. It is not difficult to perceive some common ground between the phenomenological approach and the cognitive-behavioural approach to delusions. For example, some of Conrad's case studies, as translated in an earlier paper by Bovet and Parnas 2 – e.g., case #3, in which a German soldier develops a paranoid illness after a series of failures and slights – are readily interpretable within a cognitive-behavioural framework, which emphasizes the importance of pre-existing cognitive biases and problems of self-esteem 3, 4. Freeman's model of paranoia, in particular, assigns a role to anomalous experiences in provoking the patient's search for meaning, and has been supported by studies showing associations between paranoia and sleep loss 5, cannabis use 6, hearing loss 7, and even a sudden reduction in height engineered in a virtual environment 8. Hence, I think there is much to be gained from the cross-fertilization between different approaches to understanding delusions. Here I raise some questions about how this is to be achieved, echoing, to some extent, points previously made by others who have commented on the phenomenological approach to hallucinations 9. Problems involved in reporting private experience have been long recognized in psychology and at one point led to a methodological version of behaviourism that ruled first-person reports of mental processes as illegitimate 10. Although few would take this extreme position today, the problem has not gone away. Seminal 11 and more recent studies 12 have amply demonstrated that people very often “tell more than they can know” about what is happening in their own minds. Phenomenologists argue that their methodology is not compromised in this way because it differs in some important respects from introspection. Whereas the introspectionist attempts to obtain direct access to mechanisms, participants in phenomenological studies are instructed to report raw experiences, with all their assumptions and interpretations about those experiences “bracketed out” 13, conveying them to an interviewer whose relationship with the informant has been characterized as one of radical empathy 14. Whether this distinction is always as clear as advertised is moot (phenomenological inquiries, it seems to me, often make inferences about mechanism). Even if it is, the phenomenological approach raises a more subtle difficulty that was discussed in the later philosophy of L. Wittgenstein 15 and clearly articulated by the radical behaviourist B.F. Skinner 16. Contrary to some mischaracterizations of Skinner's position, he did not doubt that we can talk about private experiences, but was puzzled about how we are able to do so. Like Wittgenstein, he saw that language is the creation of a verbal community, and that learning how to describe, therefore, requires three elements: the individual, the stimulus to be described and (crucially) at least one other competent language user who also has access to that stimulus. Consider, for example, how we learn to identify simple physical objects such as furniture. If I call a chair a “table”, I can be corrected if another member of the verbal community can see that I am looking at a chair. I can also be taught new verbal responses (“that is a chaise-longue”; or “a chaise-longue has the following features…”). These opportunities are denied in the case of experiences which only the speaker has access to, which is why so much of our language of experience is metaphorical – “a stabbing pain”, “a heavy heart” 17. Even the word “depression” is a metaphor, stolen first by psychiatrists from cardiologists to signal the opposite of excitation before being passed onwards into everyday language 18. Of course, phenomenologists are aware of the role of metaphor in experiential reports. Conrad's account of trema preceding the onset of delusions is explicitly metaphorical. Nonetheless, we are left with difficult questions about exactly what is happening when these reports are made. What kind of stimulus is being reported? And how are we to decide between different but apparently incompatible phenomenological claims such as those of, say, Conrad or Matussek? Without some kind of external criterion, these questions appear irresolvable. A possible solution is to map phenomenological reports on to other kinds of data, for example, from neuroimaging studies, as suggested by Sass and Byrom and others before them 13. A minimum first step would be to address questions of reliability (the extent to which different interviewers elicit similar or different phenomenological reports). There has been some progress in this regard, for example, the development of the Examination of Anomalous Self-Experience 19. Ultimately, this approach should lead to quantitative empirical investigations to determine in whom and in what circumstances altered reality experiences occur. For some of the phenomenologists reviewed by Sass and Byrom, for example Jaspers, the answer to the “in whom?” question is “in people with schizophrenia”. In principle, this claim could be analytical or synthetic. In the former case, what is being proposed is a narrow redefinition of schizophrenia which, I suspect, would be uncomfortable for many modern researchers. If the claim is synthetic, then empirical research is required to show that all (or at least only) schizophrenia patients (defined by some other criteria) suffer from these experiences. A Danish study of 155 consecutive psychiatric referrals found that perplexity and abnormal self-experiences (similar to Conrad's trema concept) were reported by many but not all first episode schizophrenia patients 20. Another study 21 made the apparently spectacular discovery that 70% of non-psychotic patients with so called “basic symptoms” (mostly altered reality experiences) developed schizophrenia at long-term follow-up. However, this finding looks less spectacular when it is realized that two thirds were lost to follow-up. Assuming that these patients were most likely non-psychotic, the true conversion rate was probably about 25%. Further research along these lines would clearly be helpful. However, an insurmountable difficulty is that schizophrenia is not a particularly coherent concept on any criteria that phenomenological data could be compared with. For example, family and molecular research shows a substantial shared genetic component with other diagnoses 22, 23, clinical and neuroscientific data support a continuum with mood disorders rather than separate disease entities 24, and multivariate analyses of symptom data point to multiple, independent syndromes within the broad schizophrenia envelope 25, 26. Hence, although Sass and Byrom express the hope that phenomenology might show “how syndromes (such as schizophrenia) can embody distinctive global modes of psychological life that may render symptoms (such as delusion) more heterogeneous than they otherwise appear” 1, it seems unlikely that phenomenological or, for that matter, any other kind of data could lead to a unified theory of schizophrenia. A much better approach would be to treat altered reality experiences as phenomena to be investigated in their own right. The belief that altered reality experiences are indicative of schizophrenia has no doubt been fostered by the assumption that these experiences lie beyond the realm of normal mental life. However, we should be cautious in making this assumption, especially given recent evidence of continua linking psychosis to normal human experiences 27. Altered reality experiences are typically elicited from patients during intensive questioning following a profound life crisis in which there is bound to be a search for meaning. This does not mean that they should be discounted, but it does mean that we should seek comparisons with the exceptional experiences of ordinary people, rather than with ordinary life. For example, we could compare the onset of psychosis with other sudden life changes such as religious conversion. Indeed, religious conversion bares some similarity to delusion formation across a number of dimensions. For example, adolescence is a high-risk period for both 28. It has long been recognized that religious conversion, like the onset of delusions, often occurs against a background of personal crisis 29. Insecure attachment is a predisposing factor for both religious conversion 30 and paranoid delusions 31. There may be other similarities, for example, in terms of information processing and other kinds of psychological functioning. Some studies have reported difficulty in distinguishing between religious people and patients with delusions 32, 33, although it is possible that the right questions were not asked. If we should be wary of the assumption that delusions are different from other kinds of beliefs and attitudes, a corollary is that we should be mindful that much of ordinary mental life remains poorly examined. Hence, normal beliefs and attitudes may be much more complex than we usually suppose. If phenomenological analysis is to shed light on abnormal mental states, perhaps it can begin by helping us to better understand the ordinary.