Saturday, 3 May 2008

Form, Content, Metaphor, Body, and Delusion

The notion of the 'form' of a delusion has often landed phenomenological psychiatry in a bit of trouble - if only because it seems terribly hard to spell out just what it means. Here is the way I myself used to (attempt to) distinguish between form and content:

  1. Content: What a delusional belief is about - i.e. 'intentional' or 'representational' content.
  2. Form: The rational relations of the belief to other beliefs.

The temptation is to think that delusions are conceptually manque just to the extent that the person who is deluded is making a funny bunch of inferences.

But first, like, does anyone really believe that? Are they just irrational in the sense of being poor reasoners? To my mind, this seems a million miles away from the deep kind of irrationality we meet with in, say, certain schizophrenic conditions.

Second, there appears to be an untenable dualism buried in this scheme. At least, there is if one takes it that form and content are distinct aspects of belief. As if we could understand what content a belief had without having understood the kinds of inferences that holding to it licenses us to make. It always seems intuitively obvious to me that the content somehow determined the form in the case of (delusional) belief - as if one could help oneself to a notion of content and then, from that, see what inferences it legitimated. This, however, is surely, well, at least rather doubtful. Could I really be said to understand what an expression of a particular belief meant if I did not grasp what inferences from this were and were not permitted? Would not my idiocy about formal matters reflect badly on my self-attribution of a grip on content? If we defined form and content at a sub-semantic (causal, naturalistic, non-intentional) level - as, say, a matter of the words used in the (putative) expression of a belief (for the 'content'), or of the ('formal') associations to such utterances that tend to be made, then the distinction stands. But it isn't clear that it has anything to do with the belief qua belief - nor on the delusion qua delusion.

So my question is: Can we arrive at another notion of 'form', in psychopathology, which allows us to unpack just what might be awry with delusions, in a way which doesn't commit us to the above-described untenable dualism? I think we can, but the contrast with content must be abandoned as misleading. For what the idea of a formal disturbance is, I suspect, trying to articulate, albeit badly, is the idea of a disturbance which is 'deeper' than any kind of inherently correctable 'mis' phenomenon - such as a mistake or misperception or misapprehension or misunderstanding. What is articulated, although it will take our best epistemological efforts to arrive at the necessary understanding of what we mean here, is the idea that the delusion represents a disturbance in that contact with reality that consists not simply in the absence of a 'mis' phenomenon, but rather in that contact which is a precondition for intelligible talk of take and mistake, apprehension and misapprehension, understanding and misunderstanding.

The best way, I think, to grasp what is aberrant in true delusion (and I'm including delusional mood and delusional perception in this too, since I think these labels accurately reflect a pre-understanding that the kind of disturbance we meet with here is not a function of the mistaken nature of just delusional beliefs, but something which affects the very possibility of talking of taking or mistaking in the domain of belief, mood, and perception) is through reflection on a Wittgensteinian conception of the foundations of our grasp of meaning.

One way in to start to understand the foundation of delusion is through thinking about the way in which our experience of our own body provides the causal template for so much of our understanding of causality in general, psychological comprehension, social understanding, and so much more. Consider the following:

  1. In schizophrenia we often have a disturbance in metaphorical understanding. As John Rhodes and Simon Jakes have discussed - and others before them such as Hannah Segal have noted - schizophrenic delusions often involve a conflation of metaphor and reality. The well-known example (from Segal) is of the patient who "was once asked by his doctor why it was that since his illness he had stopped playing the violin. He replied with some violence: 'Why? do you expect me to masturbate in public?'" Perhaps 'fiddling with himself' was what connected the two (musical and onanistic) cases, or perhaps it was just an associative web of more personal allusions.
  2. Much of our everyday discourse, and our capacity to learn and understand it, depends upon conceptual metaphor and our ability to grasp it. As Lakoff and Johnson suggest in Metaphors we Live By, pretty much all of our language games are metaphorically structured. Take their example: ARGUMENT IS WAR, and consider the following idioms: "Your claims are indefensible. He attacked every weak point in my argument. His criticisms were right on target. I demolished his argument. I've never won an argument with him. You disagree? Okay, shoot! If you use that strategy, he'll wipe you out. He shot down all of my arguments." We start with some grasp of what is involved in shooting, attacking, defending and so on. And then - without our ever even thinking about it - our brains use this associative structure as a template for our understanding of argumentation. We intuitively understand what someone means when they use a military metaphor, and don't even realise that it is such a metaphor.
  3. In order to be able to perform this transformation of frames, we need to be able to do two things. One is to draw on the source domain (warfare). The other is to keep the source and the target (argument) domains apart.
  4. This need to both identify yet also to differentiate underpins vast swathes of our understanding. For example, there is a sense in which we need to be able to identify with other people (nearly act, think, feel, as if we are them) whilst also holding onto our difference - in order to be able to relate to them at all.
  5. The dance of this back-and-forth between proto-identification and proto-differentiation amounts to what the analysts call the 'capacity for symbolism', which Winnicott so closely linked to the child's ability to engage in pretend play.
  6. In schizophrenic delusion, however, the capacity to effect the differentiations is lost. The distinction between self and other becomes troublesome. But so does the distinction between metaphorical and real.
  7. It is unhelpful to think of this as the literalisation of metaphor, any more than to think of it as the metaphoricisation of reality. What we have is a breakdown in a distinction which is needed before the metaphorical / literal distinction can get off the ground.
  8. The other aspect of conceptual metaphor I mentioned was their anchoring in the human body. In a fascinating paper Tim Rohrer discusses how we speak metaphorically about the landscape as if it were a body (face of a mountain, mouth of a river, foothills, etc.). He also notes that in fMRI scans during tasks involving landscape-as-body metaphors, hand sensorimotor cortex became activated. This suggests that we truly do not have to do here with, simply, a borrowing of conceptual structure and a totally separate deployment of it, but a secondary deployment constrained by the old discourse and rooted in our neurobiological habits of reaction. At any rate, the idea I need is just the one discussed in a previous post - that the body schema becomes disturbed in schizophrenia (perhaps even in an underlying compensated schizotaxia), and as a result fails to constrain, in the normal way, the uses and extensions of the word that are normally met with in the target domain discourse.
  9. The body schema, then, becomes frail and not ideal for guiding comprehension in target domains at some distance from the literally bodily. Different extensions are naturally made. Further, the ability to recognise secondary senses as such becomes lost.