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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