Jaspers’ un-understandability of delusions and the strong psychological
model of psychosis
1.Introduction
The strong psychological
psychosis model states that for all the speech, gestures, behaviour etc
labelled as functional psychosis we can show how they came about purely in
terms of psychological events in a social context in the same way as anxiety or
shyness, are continuous with normal psychological processes i.e. are not
qualitatively different states and that the meaning of what is communicated can
also be understood (Cooke, 2017). The
strong psychological psychosis model applies to ‘functional psychosis’ i.e.
where no biological cause is present that is likely to explain the psychosis
(such as intoxication with LSD or a brain tumour) (Cooke, 2017).
I will be using Jasper’s
phenomenological approach to delusions to critique the strong psychological
psychosis model. Jaspers explains “primary delusions” of schizophrenia as the
observed manifestation of a global change in awareness of the world with
altered meanings of experiences. This differentiates “delusions proper” (also
known as “primary delusions” – the terms will be used interchangeably) from “delusion-like
ideas” resulting from understandable responses to morbid events e.g. depressive
guilt (Jaspers, 1963): 96). In “delusions proper” there is a core to the
underlying experience that is not accessible to others understanding as they do
not share this changed awareness of the world (Jaspers, 1963: 282). Jaspers
describes this phenomenon as a qualitative change from normal or everyday
experience that cannot be understood due to lack of shared meanings. This
concept if true is problematic for the strong psychological psychosis model that
emphasizes continuity with normal experience and that we can understand the
meaning of utterances and behaviour in psychosis.
In this essay I will describe
initially how the strong psychological psychosis model views understandibility
of psychosis symptoms and continuity with normal experience before discussing
how Jaspers characterises “delusions proper” as being the external
manifestation of an “ununderstandable” experience. I will then discuss this
specific meaning of “ununderstandable” for “delusions proper” and why this
contradicts the strong psychological psychosis model. I will then discuss some objections that can
be made to Jasper’s ideas by strong psychological psychosis model advocates and
how these can be answered.
2. The Strong Psychological Psychosis Model
Now I will briefly summarise
the assumptions of the strong psychological psychosis model.
For ‘moral’ reasons including
reducing stigma some emphasise continuity between psychological phenomena
labelled psychosis and those regarded as normal (David, 2010). Some
interpretations of research findings can also be said to demonstrate psychosis
being at the severe end of a continuum with normality (Jones et al, 2003;
David, 2010 and Linscott and Van Os, 2010). The utterances and behaviour of
people experiencing psychosis are said to able to be understood through the
joint process of creating a collaborative psychological formulation -
“assumption is that this process
will render even the most unusual or disturbing behaviour and experiences
understandable: ‘…at some level it all makes sense’ (Butler, 1998, p.2)”
(Division of Clinical Psychology, 2011: 6).
The strong psychological
psychosis model asserts that experiences, utterances of behaviour that are
labelled as psychosis can be
“understood
and treated in the same way as other psychological problems such as anxiety or
shyness” (Cooke, 2017: 6)
An example of how
psychological formulation is presented as understanding the patient’s psychosis
can be found in ‘Understanding Psychosis’ (Cooke, 2017: 51-52). This
formulation however demonstrates connections between life experiences and relevant aetiological factors (such as
substance abuse) with the onset and
maintenance of psychotic symptoms as a general class but not why they had such
specific experiences such as thought broadcasting through a lump in his throat.
It also gave no impression of how did this feel to the person having these
experiences. This issue is ignored in ‘Understanding Psychosis’. This contrasts
with panic disorder formulations (for example Wells, 1997: 105) where it is
easier for me to place myself in the patient’s mind and body and experience
what they are going through with increased anxiety leading to physical symptoms
such as heart racing and breathlessness and fears of having a heart attack.
The strong psychological
psychosis model holds that in ‘functional psychosis’ there is a continuity
between psychosis and normal experience, that the utterances and behaviour in
‘functional psychosis’ can be understood and that the occurrence of psychosis
and the content of utterances and meanings behaviour can be explained entirely through
psychological processes in a social context.
3. Jaspers Concept of Primary Delusions and Delusion-like Ideas
Now I will describe the
phenomenological model of delusions which clashes with the strong psychological
psychosis model (Picardi et al, 2018) of which Jaspers is the most renowned
exponent.
Jaspers has been influential on
psychiatry in general and on psychosis specifically (Stanghellini and Fuchs,
2013) and psychiatry has a substantial influence on the conception and
treatment of psychosis despite the objection of strong psychological psychosis
model advocates (Cooke, 2017 and Cooke et al, 2019). Jaspers’ phenomenological
method consists of
“classifying
psychic phenomena” (Jaspers, 1968: 1314), “the sorting out, defining,
differentiating and describing of specific psychic phenomena, which are thereby
actualized and are regularly described in specific terms” (Jaspers, 1968:
1315-1316) and “must set aside all outmoded theories, psychological constructs
or materialist mythologies of cerebral
processes” (Jaspers, 1968: 1316).
This classification of
“psychic phenomena” is the essential foundation of further classification,
research and clinical practice. A
comparison is made with the histologists describing what they see of the
relevant morphological features that others can recognise (Jaspers, 1968;
1316). Jaspers concept of “primary delusions” with global change in awareness
of reality with changed meanings permeating many aspects of experience (Jaspers,
1963: 93, 103-104) has a convincing ‘face validity’ for explaining the unusual,
baffling enigmatic experiences, behaviour and utterances that clinicians who
see patients with psychosis encounter. This is reinforced by the
phenomenological descriptions of patients’ experiences in ‘General
Psychopathology’ (Jaspers, 1963) of which elements can be readily recognised
for clinicians seeing patients in their own practise as Jaspers hoped with his
histology comparison. For my own clinical practise in an Early Intervention in
Psychosis team I find Jaspers’ concepts of “primary delusions” and
“delusion-like ideas” useful as an explanans for why patients that I assess
have highly unusual experiences and behaviour whilst also using elements of the
weaker psychological psychosis models especially for “delusion-like ideas”. In my own clinical practice, I find that the
claims of strong psychological models of psychosis fall short in helping me to
understand why this person is having this particular experience and what it
feels like and why are they saying what they are saying (see 2.).
How does Jaspers separate
“primary delusions” and “delusion-like ideas”? The “external aspects” used to
recognise delusions are “vaguely applied to all false judgements…1…held with an
extraordinary conviction…incomparable subjective certainty; 2….imperviousness
to other experiences and to compelling counter-argument; 3. Their content is
impossible.” (Jaspers, 1963: 95-96). Jaspers is identifying a group of “false
judgements” that can be recognised using these “external aspects” including “delusion-like ideas” or “delusions
proper” but could also include some examples of strongly held extreme political
or religious beliefs due to “master interpretive systems” (Bentall in
Bortolotti, 2018: 79-81 and 87). The “impossible” criterion is discarded
nowadays as what is regarded as impossible varies with different cultures and
some delusions e.g. of jealousy are possible.
These external aspects are themselves
products of “judgments” based on “experience”. These experiences may be morbid
events such as depression or hallucinations leading to “delusion-like ideas”
but “delusions proper” are caused by “psychologically irreducible” “alien” experiences
(Jaspers, 1963: 96). What is distinctive
about the underlying form or mode of experience associated with “delusions
proper” that is different from other “false judgements” even if the content is
similar (Jaspers, 1963: 58-59)? Jaspers distinguishes between the content of
experience and its form which describes the nature of how the experience is
presented to consciousness. Jaspers uses “hypochondriacal concerns” to
demonstrate the difference – it may be experienced as a recurrent intrusive concern
that one is unwell, or it may be a strong belief of being ill despite evidence
to the contrary or hearing a voice saying that one is sick. Whilst the content
is similar, the mode of its experience is different (and different clinically
useful implications for diagnosis, prognosis and treatment).
In “delusion-like ideas” the mode of
experience can be grasped empathically as an understandable consequence of
another morbid psychic event (see 5.). For “delusions proper” we cannot
achieve “static understanding” (see 4.)
of the mode of experience that underlies the delusion producing “judgements”
expressed in utterances and behaviour for reasons I shall discuss now.
Jaspers notes that people’s
experiences and perceptions of the world involve meanings – when we perceive an
object it is accompanied simultaneously with implications –
“a house is
there for people to live in…If I see a knife, I see a tool for cutting” (Jaspers,
1963: 99)…“experiences of primary
delusion are analogous to this seeing of meaning, but the awareness of
meaning undergoes a radical transformation. There is an immediate intrusive
knowledge of the meaning and it is this which is itself the delusional
experience” (Jaspers, 1963: 99).
People or everyday objects can
acquire new often threatening or otherwise significant meanings. This can occur
in several types of experience – such as perceptions, ideas, memories or
awareness. The radically changed meanings then spread throughout interpretation
of memories, current and recent past experiences and interpretation of current
and future experience.
“Later the
identical experience of significance is repeated, though in other contexts. The
trail is blazed and the preparedness for the significant experience then
permeates almost all perceived contents. The now dominant delusion motivates
the apperceptive schema for all future percepts.” (Jaspers, 1963: 103-104).
Delusional mood is described
as one example where initially subtle then progressively more compelling
changes in the meanings of experiences are accompanied by mood changes such as
anxiety which result in formation of a “primary delusion” (Sass and Pienkos,
2013).
The incorrigible nature of
“delusions proper” is not like the “normal errors” of people reinforced by the
values and beliefs of a social group (as would occur for extreme religious or
political views that may meet the external characteristics criteria for
delusions) nor is it like understandable psychological consequences to a prior
morbid event of “delusion-like ideas” but is instead an
“alteration
in the nature of personality, the nature of which we are so far unable to
describe, let alone formulate into a concept” (Jaspers, 1963: 105).
Jaspers holds that in
“delusion-like ideas” there is a connection with other morbid events such as
depression but in “delusions proper” there is a global change in awareness of
experience with changed meanings of experience but why does this make such
states “ununderstandable”?
4. Ununderstandibility of delusions proper
In this section I will outline
what Jaspers means by “understanding” of experiences and “ununderstandibility”.
Jaspers separates “genetic understanding”
from “static understanding”. “Genetic
understanding” describes
“empathy, of
perceiving the meaning of psychic connections and the emergence of psychic
phenomenon from another” (Jaspers, 1963: 27). “Psychic events ‘emerge’ out of
each other in a way which we understand” (Jaspers, 1963: 302).In terms of the
content of the patient’s utterances, “if we understand the contents of the
thoughts as they have arisen out of the moods, wishes and fears of the person
who thought them we understand the connexions psychologically or
empathically…called ‘psychological understanding’…empathic connexions leads us
into the psychic connexions themselves.” (Jaspers, 1974, 83).
The “static understanding” of
any experience which is not directly visible to the senses of the observer such
as a delusion is a
“subjective
symptom” that has “to be grasped by transferring oneself… into the other
individual’s psyche; that is, by empathy. They can only become an inner reality
for the observer by his participating in the other person’s experiences, not by
any intellectual effort. .. Then there are all those psychic experiences and
phenomena which patients describe to us and which only become accessible to us
at secondhand through the patient’s own judgment and presentation. Lastly,
subjective symptoms also include those mental processes which we have to infer
from fragments of the two previous kinds of data, manifested by the patient’s
actions and the way he conducts his life” (Jaspers, 1968: 1313).
When Jaspers refers to
“primary delusions” being “ununderstandable” this seems to be referring to
“static understanding” rather than “genetic understanding” of meaningful
connections and to the underlying experience that leads to the manifestation of
the delusion (Gorski, 2012). Jaspers concept of what is “psychologically irreducible”
(Jaspers, 1963: 96) in “delusions proper” refers to his concept of
“irreducible quality of psychic phenomena,
which can only acquire identical meaning for numbers of people through the
incentive and the multiple clues and leads mentioned previously, may already be
found in the case of the simplest sensory qualities, such as red, blue, colour,
tone; it comes into play also with spatial awareness, object awareness,
perception, imagery, thought, etc.” (Jaspers, 1968: 1317). “We can have no psychological understanding
without empathy into the content (symbols, forms, images, ideas)” (Jaspers,
1963: 311).
Understanding thus requires
empathy which in this context requires shared meanings. In the underlying
experience all or some experiences may have changed meanings and they are not
shared i.e. are not “identical” between the person with the delusion and the
person trying to understand them. The basic shared meanings for time,
perception or object awareness and so forth may not apply. An example of these altered meanings as part
of the underlying experience has been described by Renee (quoted in Sass, 2003:
130).
“I looked at a
chair or a jug, I thought not of their use or function—a jug not as something
to hold water and milk, a chair not as something to sit in—but as having lost
their names, their functions and meanings; they became “things” and began to
take on life, to exist.”
Note the disjunction between object and
typical shared meaning. We can view this experience as a whole description of a
world with different/ lost meanings at higher levels but not at the level of
shared meanings as every experience or object needs to be checked what the
meaning is to the person. Hence “chair” is not a shared meaning between Renee
and the person talking to her – the shared meaning would have to be at a higher
level – a translation guide for these different experiences/ objects i.e. the
“psychologically irreducible” level is the translation guide for this anomalous
experience describing the experience in terms of altered meanings. As Sass
pointed out Renee is unusual in being able to convey these differences in
meanings, in producing a translation guide, often such a guide is absent with
the patient saying ‘I don’t have the words to describe it [the experience
underlying the delusion].’
One of the key difficulties in
understanding the experience that lies behind the “delusion proper” is that it
is difficult for other people to “grasp” this experience by “transferring into
the other individual’s psyche” because of the changed meaning of experience. The
person trying to understand the person with the “delusion proper” is trying to
navigate an experiential space where what seems like it could have identical
meaning may have a different meaning to the person having the experience
unpredictably. This is seen in patients displaying ‘double orientation’ where
their behaviour is different from what is suggested by what they say – the
classic example of people saying they are royalty but apparently content to
stay on psychiatric back wards – which suggests more than one meaning may be
held by the same person for the same term.
The patient
“lives in two worlds simultaneously, the real
one …and his psychotic one” (Jaspers, 1963: 150).
This inconstancy of meanings and difference in
meanings mean no easy shared understandings is possible when trying to form
“static understanding”. The necessity of using a guide, to continually stop and
check whether they have got the meaning right prevents the “grasp” by “empathy”
involving a lack of “intellectual effort” that Jaspers describes is the essence
of “static understanding”. Even if accurate translation guides are present the
resultant staccato “intellectual effort” nature of the exploration of the
experience stops the rapid empathic processes. In some cases there is an
absence of this guide preventing any sort of “grasp” at all. Since we lack the
same meanings we cannot directly perceive them by empathy and require
interpretation by the patient these
“phenomenological elements…. which can in
principle never be seen by us,...we term ‘statically ununderstandable’”
(Jaspers, 1963: 578).
If one could produce an
accurate translation guide that could be applied reliably this may lead to an interpretation of the patient’s
“subjective symptoms” but interpretation
is not the same as “static understanding” as defined above. Even so, it could
be argued that if the rules and meanings of this experience manifesting in
“delusions proper” are radically different to everyday commonplace ones then we
still may not be able to make sense of these different ways of meanings
attached to the world (Thornton, 2004: 223-224). If one could understand
through shared meanings of the same experiences i.e. that “static understanding”
is possible Jaspers would state that is not a “primary delusion” but is instead
a “delusion-like idea”.
Jaspers concept of
“un-understandability” does not mean that the contents of utterances or the
gestures of behaviours associated with the experiences underlying “delusions
proper” are valueless. He noted that
“in psychotic
reality we find… fundamental problems of philosophy…the extremest of human
possibilities…the philosopher in us cannot but be fascinated by this
extraordinary reality and feel its challenge” (Jaspers, 1963: 309).
Jasper’s concept of
“ununderstandability” refers to the difference in meanings of experiences
caused by the global change in awareness of the environment,
“a mutation in
the ontological framework of experience” (Sass and Byrom, 2015),
and this lack of shared meanings means that
“static understanding” is not possible because observers are not able to
rapidly grasp empathically what the patient experiences.
5. Delusion-like ideas, genetic
understanding and the strong psychological psychosis model
In this section I will focus
on delusion-like ideas and where there is compatibility between the strong
psychological model and Jasper’s concepts.
In the strong psychological psychosis model
there is a core assumption that delusions are wholly understandable through psychological
formulation (Division of Clinical Psychology, 2011: 6) and for this to happen
then the form of experience underlying “delusions proper” has to be eliminated
and replaced with analysis of the content. The form of “primary delusion” involves
disjunction not continuity with everyday psychological phenomena which is
emphasised in the strong psychological psychosis model. For “delusion-like
ideas” the mode of the experience has continuity with everyday psychological
phenomena so this form does not have to be rejected. Jaspers says that
“the psychologist
who looks for meaning
will find content
essential and the
form at times unimportant”
(Jaspers, 1963: 59).
Jaspers
drew a distinction in understandability between “delusions proper” and
“delusion-like ideas”.
“The most
profound distinction ….between what is meaningful and allows empathy and
what…is ununderstandable, ‘mad’ in the literal sense…Pathological life of the
first kind we can comprehend…as an exaggeration or diminution of known
phenomena…Pathological psychic life of the second kind we cannot adequately
comprehend in this way. Instead we find changes…for which we have no empathy
but which…we try to make comprehensible from an external point of view”
(Jaspers, 1963: 577).
For “delusion-like ideas” they are an
“exaggeration or diminution” of psychological phenomena we can grasp at with
empathy through shared meaning – if someone was depressed we can grasp they may
feel guilty and then form delusions of guilt that their family is
ruined–something that can be grasped by us and is not a disjunction with normal
psychology in contrast to “delusions proper”. Here we can see common ground
between the strong psychological psychosis model and “delusion-like ideas” in
that they are regarded as being at the extreme end of continuum with normal
psychology that we can achieve “static understanding” of.
Further common ground also
exists in the strong psychological psychosis model’s assertion that if we knew a
patient’s life history and their personality then we can appreciate why they
experience “delusion-like ideas” in the same way we can for anxiety or shyness
(Cooke, 2017). The DCP guidelines on formulation (Division of Clinical Psychology,
2011: 6) emphasise how the utterances and associated behaviour that are called
delusions should be framed in terms of the person’s context, life experiences
and psychological processes continuous with normality and that if we do it
“makes sense”. This is what Jaspers
refers to as “genetic understanding” (see section 4.) using empathy in a specific sense
“We sink ourselves into the psychic situation
and understand genetically by empathy how one psychic event emerges from
another.”(Jaspers, 1963: 301) “When we understand how thoughts rise from moods,
wishes and fears we are understanding the connections in the true psychological
sense, that is by empathy (we understand the speaker)” (Jaspers, 1963, 304).
This could easily apply to the
part of the psychological formulation (see 2.)
as to how a clinical problem came about. For “delusions proper” there may be
some aspects from a patient’s life history and previous morbid psychological
events that we can see linking together as part of “genetic understanding” but
at some point this fails as we are unable to follow the psychological
connections to the experience underlying “delusions proper” as we cannot
achieve “static understanding” of important aspects of this state (Sass and
Pienkos, 2013 in Fulford et al, 2013: 644) for reasons explained in 4. We may see a patient with a history
of childhood trauma then a triggering life event that we can grasp as
generating vulnerability for mental health problems but understanding is lost
when they talk about Martians are passing electricity through their body.
Psychological Formulations
also include ‘maintenance factors’ i.e. why does the problem not resolve
itself. In the cognitive model of delusions several maintenance factors are
outlined including anomalous states (Freeman, 2016). There is often also a
diagram showing a variety of thoughts, feelings and behaviour in an environment
interact with each other. Jaspers may refer to this interlocking system of
beliefs and processes as “rational understanding” and “relational
understanding” (how mental contents relate together).
“Rational…understanding…is a purely cognitive
understanding of rational content, common to all (e.g. we can understand the
logical structure of a delusional system in which an individual lies
submerged)” contrasting with “empathic understanding - is the proper
psychological understanding of the psyche itself” (Jaspers, 1963: 307).
Jaspers conception of
“delusions proper” does not necessarily rule out one contention of the strong
psychological model of psychosis – that the aetiology of ‘functional psychosis’
is always due to psychosocial causes so long as a mechanism for these causes to
cause this disjunctive state can be demonstrated.
The strong psychological
psychosis model would not recognise the distinction between “delusion-like
ideas” and “delusions proper” and just view them all as delusions. The
definitions of delusions in classification systems used in research - for
example, DSM-V (American Psychiatric Association, 2013: 87) - or rating scales
used to measure delusions in research - for example, PANNS (Kay et al, 1987) –
are based on the external characteristics of delusions which are shared between
“delusions proper” and “delusion-like ideas”. As these are lumped together in
classification and measurement then advocates of the strong psychological
psychosis model will often not be presented with research that contradicts
their view. On the other hand the research demonstrating continuity with normal
psychology often fails to convince in the clinic when faced with examples of
“delusions proper” due to failure to achieve “static understanding”.
In summary, some elements of
the strong psychological psychosis model is compatible with Jaspers especially
for “delusion-lie ideas” but the disjunction with every day experience and
psychology and inability to achieve “static understanding” which Jaspers
proposes as underlying “delusions proper” is not.
6. How can the
Strong Psychological Psychosis Model deal respond to Jaspers?
I will now discuss how one
prominent strong psychological psychosis model advocate Bentall questions the
phenomenological method. Bentall states the difficulties of people reporting on
their own experiences, whether phenomenologists can “bracket out”
preconceptions completely and the problems of trying to understand what people
are communicating about private experience often using metaphor (Bentall,
2015). The second concern seems to be about the true objectivity and
reliability of the method but any observation is impacted upon by
preconception, the important matter is whether like the histologist the
resultant description allows recognition by others and Jaspers’ vivid
descriptions and subsequent classifications passes this test. The first point
also refers to what Jaspers refers to as “subjective symptoms” and his answer
may be that it relies on the skill of the phenomenologist but to ignore
“subjective symptoms” for “objective symptoms” would seriously impair understanding
what patients experience by focussing on measuring external aspects Jaspers, 1968: 1313). The third point would
be used by Jaspers to say Bentall has proved Jaspers’ point – the patient is
forced to use inadequate metaphor because of the lack of shared meaning. People
in the same culture often use common metaphors for inner experience such as
“butterflies in the stomach”. These
descriptions are sound odd but because they are shared metaphors we can at the
least come close to what they feel like or mean unlike experiences underlying
“delusions proper” which are so different from everyday experience that shared descriptions
seem impossible – how does it feel to have one’s thoughts be broadcast or withdrawn
and how to communicate this to somebody not having these experiences?
Bentall could point to phenomenological
theories on understanding “delusions proper” such as from Minkowski,
Blankenburg and Kimura (Sass, 2001), Maher,(Maher, 1974), Sass and various
colleagues (Sass and Byrom, 2015 and Sass and Pienkos, 2013), Rhodes and Gipps
(Rhodes and Gipp, 2008) but they all involve complicated mental steps that
preclude “effortless” static understanding and in any case are based on
qualitatively different experiences discontinuous from normal psychology.
7. Conclusion
Jaspers concepts of “delusions
proper” and “delusion like ideas” with former term used to describe experiences
that are qualitatively different from normal experience (and are “ununderstandable”
due to the subsequent lack of shared meanings) with the latter term used for
delusions that can be understood as responses to prior morbid mental events These
concepts seem closer to the reality of psychosis encountered in the clinic than
the strong psychological psychosis model which regards all psychosis as
continuous with normal psychology and is always able to be understood.
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