Posted by alexandra_k on August 22, 2005, at 19:34:22
In reply to Re: The Problem of Action, posted by alexandra_k on August 22, 2005, at 19:29:07
Treatment Implications
Traditionally it was thought that delusions were not amenable to reason and thus it was pointless to attempt to argue delusional subjects out of their delusion. Fairly recently, however, there has been a move towards offering cognitive therapy as treatment for them. Cognitive therapy is based on the notion that ones thoughts leads to ones emotional responses leads to ones actions. Thus, the paranoid subject does not feel fear and then come to their particular delusional belief in an attempt to explain or make sense of their experience of fear. Rather the notion is that the delusional belief is what is responsible for the person’s experience of fear.
Cognitive therapy attempts to alleviate their experience of fear, for example, by providing counter-evidence to the delusional belief. It is thought that by doing this and by making any contradictions explicit this will weaken the person’s sense of conviction or certainty that the delusion is true. This is thought to have the ultimate consequence of alleviating their experience of fear.
In looking at case reports of interviews with delusional subjects where therapists attempt to apply this line of reasoning to persuade people that their delusions are false I can’t help but wonder whether the therapist and delusional subject aren’t continually talking past each other. One of the main problems they have found with attempting this kind of treatment is that it is hard to build a good rapport between the therapist and the delusional subject and that there are high drop out rates as the delusional subject simply stops going to therapy.
If we grant that delusions are reports of certain kinds of experiences, or at the very least that the sense of conviction or certainty is primary and would be appropriate if associated with the anomalous experience then we may be able to explain why it is that the delusional subject shows such resistance to backing down on their delusional utterances. When people attempt to offer evidence to the contrary they may well be missing the point that the evidence is not relevant as the subject is instead attempting to report on the nature of their experiences.
If we can instead attempt to think our way into the kinds of experiences that may lead to them expressing them in the way in which they do then we may be able to arrive at an understanding of why they insist on their delusional utterance despite everyone attempting to argue them out of their delusion. Rather than by engaging in radical translation to explain how they can believe what they are saying we can engage in radical empathy to understand why they say the things they do.
Perhaps it is as Walkup notes:
The distinction between a description of the experience (sometimes called a phenomenological description) and the description of the factual state of affairs is scientifically and clinically important. Scientifically, a subject who consistently failed to describe the perception of certain illusions would be suspected of some visual or neurological abnormality. Clinically, the therapist who challenges a patient’s description of his or her experience may sound absurd, just as would a vision researcher who insisted to an experimental subject that the two lines in the Muller-Lyer illusion actually look the same length (Walkup, 1995 p. 326).
If the delusional subject is indeed reporting on their experience then they are entitled to a hold onto their experience with certainty. I wonder whether attempts to challenge delusional utterances by trapping subjects in contradiction is what ultimately leads them to endorse contradiction in order for them to retain the certainty about their experience. What might be happening here is an unfortunate state of affairs for the delusional subject who might be hard pressed to find an appropriate alternative expression of their experience. Rather than focusing on the logic of their utterance I wonder whether we might have more luck with attempting to empathize with the subjects anomalous experience. Not with the view to arguing subjects out of their delusions, but with a view to attempting to understand what they might be trying to say. And with the ultimate view of assisting them in finding more appropriate ways of expressing themselves. Rather than attempting to argue them out of their delusion by presenting evidence that is not even relevant to what they are saying one might have more luck with trying to express some empathy for the anomalous experience that they are having.
What I would like to suggest is that regardless of whether the subject actually has made the move from expression of experience to false belief about reality one may be better off establishing rapport by validating the sense of conviction or certainty which is appropriately associated with the subjects anomalous experience. Perhaps the trouble with subjects who have come to false beliefs about external realty on the basis of experience is that they have lost sight of the distinction between appearances and reality by becoming over-focused on their anomalous experience. Davies et al., talk about this as a failure to inhibit believing what they perceive, and it sounds to me that the move from experience to external reality is a lot like the notion that delusional subjects have lost their ability to ‘reality test’. The notion behind reality testing is that one should test ones hypotheses about reality against reality. The delusional subject does not seem to do this and one enumeration of this might be that external reality is irrelevant to the reality of ones experiences, and ones experiential reality is certain. One way to ultimately lose the appearance / reality distinction is to focus on appearances to the point that the external world is completely disregarded. Perhaps what has happened here is that the delusional subject has become lost in appearances being reality where their experiences are sufficiently anomalous.
This line places a heavy explanatory burden on the nature, intensity, and recurrence of the subjects anomalous experience. I think that this line shows better prospects for being able to naturally handle the fact that delusional subjects seem quite certain and are quite insistent on their utterances. It is also able to naturally handle the fact that the majority of delusional subjects do not act in ways in which we would expect were they to believe their utterance to be true of the external world.
It may be that there are two different things that we can construe the delusional subject as doing in making their utterance. We could consider that they are making a false claim about the world, and indeed in some cases I think this might be so. The other way we could go, however, is to consider that they are attempting to express their anomalous experience. The DSM considers that delusions are ‘false beliefs about external reality’ but this seems to beg the question by saying that delusional subjects should be construed as intending to do this. It may be that many subjects who utter claims characteristic of certain kinds of delusions are classified as being delusional and yet they intend their utterance to be a report on their experience. It may be that only when the subject is making a false claim about the world that they are appropriately classified as delusional because this is the way the APA defines delusion to be. We could thus consider that subjects who are reporting on their experience are not in fact delusional because delusions proper involve making a false claim about the world. But the other way we could go is to say that these subjects clearly are delusional and this shows the inadequacy of the APA definition of delusion. It seems that not a lot rests on this linguistic decision. Either way it is interesting that more people do not act on their delusion than people who do. A large class of the utterances that are typically considered to be paradigmatic examples of delusional utterance would seem to be better explained by the report of experience model, and the class of phenomena requiring explanation by a false belief model has been significantly reduced.
poster:alexandra_k
thread:543149
URL: http://www.dr-bob.org/babble/write/20050807/msgs/545322.html