Sunday, 22 September 2013

psychosis: a dynamical systems approach

Today I'm going to outline a template for understanding psychosis using dynamic systems theory. It is not itself a theory, being far too rudimentary. But it is perhaps a scaffold on which a theory could be built.

Here are some central ideas from dynamic systems theory. First, a dynamic system is one that keeps itself in balance. It self-regulates - like our home heating systems with their thermostats linked directly to the boilers to turn them on and off. Second, it does this in response to the demands put on it by the local environment. In hot weather the body sweats more to cool down; when it cools down enough, it stops sweating. The internal milieu is thereby maintained. Third, complex systems are autopoetic: the systems are self-creating, not simply maintaining a pre-existing structure within certain homeostatic limits, but rather organising and repairing their own structure. Fourth, such systems can operate at different levels of equilibrium. We do not have to do with a single mode of functioning that is maintained despite the pressures it is under. Rather we have to do with a system that, when maintaining its equilibrium in one configuration becomes highly challenged and too difficult, can jump to different forms of organisation that cope better with the particular challenges now encountered. Quite different orders emerge out of the same ingredients through saltatory steps.

And here is the application to psychosis. First, that everyday perception and cognition which is amenable to 'reality testing' involves one mode of organisation, which is maximally adaptive to the demands of the situation. At its best this mode promotes maximal engagement and maximal self- and other-understanding. However it leaves one vulnerable to hurt, rejection and to needs not being met. Second, that psychosis involves a step into a quite different mode of organisation, a mode which shortcuts reality testing. At this simpler level of functioning, fantasy and reality collapse into one another. Wish and fear are not now separate from real experience: the system is no longer expending energy to keep the two functions of fantasy and reality separate. Third, that the system moves into this mode of functioning when the emotional stressors on it are, for the domain in question (reality testing is not a global cognitive faculty; it operates in many different domains, and a person only becomes out of touch with reality in a limited range of these domains: patients are not usually globally psychotic), too great to handle. Fourth, that anxiety is a perturbation, an instability, in the dynamics of the system - a perturbation enough to invite a transition from a normal into a paranoid mode.

Fifth, It takes energy to separate reality from fantasy. Making the self-other distinction takes effort. Drawing the line between you and I in the right place involves a relaxed flexibility. Tiredness and overwhelm get in the way. We are normally sustained in our reality-contact by healthy relationships and by 'internalisations' of healthy relationships. By the latter is meant: we have developed forms of complex stability-promoting reality-contact through early relationships, and these sediment out a reliable re-usable structure within the self, a capacity to now enter adaptably into new relationships and maintain the stable but flexible give-and-take that constitutes real relating.

So, the main point of the dynamic systems framework for thinking about psychosis is the way it helps us think about the relation between psychotic and non-psychotic modes of function. One of the clinician's therapeutic tasks is to help a local system to change its total form, to find the small nudges that will enable a quite different order of world-relation to emerge. The framework also helps us to not focus on the content of delusional beliefs (although such content may provide important clues) but instead to think about the embedding system and its mode of function. Given that the different systems (psychotic and non-psychotic) are enactive in character, involving different perceptuo-motor cycles for example, the stabilisation of a transition into a non-psychotic world could be aided by particular forms of self-world engagement. 


Another way in which the dynamic systems framework is, I hope, relevant is that it is not intended as a metaphor for a psychological theory. The difficulty I am imagining, for the system which is finding itself unable to continue to self-organise in a reality-contact-oriented manner, and which therefore makes a saltation to a psychotic mode of function. The details of the delusional world are the result of such a saltation. The very form of mind consequent on the saltation is quite different. It is not that we have to do with psychological steps - rational, emotional, or otherwise psychologically intelligible steps - within a mode of function.

I say: not a psychological theory - but of course what does and doesn't count as psychological is not a hard and fast fixed concern. One theory which we might want to call 'psychological', and which I believe is compatible with the outline I'm offering here, is Bion's idea of a breakdown in what he calls 'alpha function' in psychosis. The idea is that it is the processes which lead to the genesis of normal mindedness which itself becomes unbearable and unfeasible in psychosis - i.e. that it is not processes which occur within already formed minds which are in trouble. 

To take just one possible example, imagine if a personality, rather than being able to body forth into a psychologically unified single sexual identity, tried to do justice to its own proto-sexual libidinal drives by sedimenting now or then in two different gendered directions, neither of which had space within it for the articulated mind-creating forms of the routes of instinctual satisfaction of the other. An unstable oscillation could result if normal repressive mechanisms did not suffice to cut off the identity which another dominant identity could not accommodate. The mind would be torn apart, and psychosis would result when conflict at a purely psychological level became unmanageable. The result is a shift to a different level of neurological self-organisation in which the very project of reality-contact - i.e. the project of allowing desire and perception to organise a stable self-world distinction and interaction - would in this domain be abandoned. 

The psychotherapeutic task would here be one of trying to create a broader identity to accommodate all of these instinctual consolidations - and I think it important to note that this task is not best understood as one of merely developing a bisexual self-conception, but rather one of the lived body itself somehow developing a hitherto missing libidinal flexibility. 

Monday, 2 September 2013

un-un-un-understandability

So here's my notes for a forthcoming talk to form part of the academic afternoon on 'Philosophy and Psychiatry: 100 Years after Jaspers'General Psychopathology at St Bart's Hospital London this Wednesday.

Introduction

The understandability or otherwise of belief is often presented as all of a single sort. Jaspers, the clinical psychologists (e.g. Richard Bentall, John Read, Jim Geekie) tell us, was too pessimistic in telling us that the irruptive, bizarre and out-of-character character of primary delusional beliefs renders them unintelligible. Whilst those evil psychiatrists are busy writing off the delusional subject as empathically unreachable in their delusion, we valiant psychological knights can show just how the content of the delusions is linked to the patient's sense of self and bring them back within the fold of humane understanding. Hmmm...

In what follows I will sketch out a more nuanced view of what I will urge are the quite different forms of understanding that we can and can't bring to bear on the schizophrenic subject in his or her delusion, and suggest that these can sometimes be disjunctive. Moreover some forms of understanding - such as those offered us by psychoanalysis - are complex in character, requiring that we grasp the causal underpinnings, the state of mind, and the dynamic (motivational) function of the delusions all together. Schizophrenic-type delusions are, I suggest, rightly understood as unintelligible in terms of the modes of intelligibility we characteristically bring to bear on one another as part of ordinary social life. However quite different modes or forms of understanding can be brought to bear on them in an intercalated manner.

The right answer to the question of whether we can understand schizophrenic delusion is therefore 'yes and no'. Moreover it would be out of place of us to attempt to deploy those modes of understanding that do find some footing with the schizophrenic person in their delusion were it not the case that they were ununderstandable in the more ordinary sense.

Below I focus mainly on the forms of understanding offered us by psychoanalysis and phenomenology. The four forms of intelligibility of belief I look at are: a) empathically achieved everyday social and individual contextualisation; b) grasp of the causal structure and processes underlying the belief formation; c) fathoming of the embedding form of subjectivity - the state of mind - the mode of being-in-the-world - in which these beliefs arise (both static and diachronic); d) uncovering the motivational (defensive) dynamics driving the belief formation and maintenance.

a) Everyday Intelligibility

How do we ordinarily understand why people believe what they do? Well, we might consider how they are aligned with the good,  the true and the rational. So for example we might say: 'He believes that he should go and help her because it is the right thing to do'. We may also make sense of why people believe what they do in terms of their direct exposure to certain situations or to testimony from others about these situations. There is nothing particularly psychological about such forms of understanding: they do not make reference to the personality, to the emotional needs of the individuals, to interferences with reason, etc. Instead the intelligibility comes just from the person being normatively aligned with the interpersonally available standards for situationally apt thought.

The delusionality of delusional beliefs, I believe, is partly - but only partly (see c) below) - a function of precisely their unintelligibility in this fashion.


b) Causal Structures and Processes Underlying Belief Formation and Maintenance

What supports and what disrupts our processes of belief formation? One philosophically informed cognitive neuropsychological project of understanding delusion views it as a failure of belief formation and maintenance. This seems unlikely to me for reasons elaborated elsewhere. (Delusions, I believe, are disturbed beliefs - but they are not disturbances of belief (formation/maintenance). The disturbance which shows itself in schizophrenic delusions is not a disturbance in thinking but in what in psychiatry we call 'reality contact', the nature of which contact requires careful specification. A quick analogy should help here: Imagine that we find that a cog within a threshing machine is spinning in an unusual manner. We might for a while, if we imagine that the normal context of threshing is all in place, investigate local failures in the mechanism surrounding this cog. But delusion, it seems to me, is more akin to the threshing machine no longer being deployed in a field of corn, but instead being towed along the road. Whatever unusual spinning we notice in the cog is a function not of the local mechanics but of the different terrain.) But nevertheless there are of course various processes and structures within and without the brain which enable us to form and maintain all sorts of beliefs. We need to be neurologically healthy, and to live in a social environment where discursive practices facilitate the relaxed formation, rehearsal, interrogation and elaboration of our beliefs. So it is surely possible to tell a causal account of normal belief formation, even if delusion is not intelligibly understood as resulting from a disturbance within such mechanisms.

Here is a causal account of delusion owed to German Berrios (1991): that 'Delusions are likely to be empty speech acts [sic], whose informational content refers to neither world nor self. They are not the symbolic expression of anything. [Their] ‘content’ is but a random fragment of information ‘trapped’ in the very moment the delusion[s] becomes crystallised. The commonality of certain themes can be explained by the fact that informational fragments with high frequency value also have a higher probability of being ‘trapped’.' The causal account - it is not yet an explanation - specifies a neurological process of crystallisation. The content of the delusion is in this perspective an irrelevance; it might tell us about the preoccupations of the subject, but such preoccupations are not part of reason for the crystallisation itself (contrast psychodynamic accounts). 

Or we might look at cognitive neuroscientific accounts of delusional perception. For example, Hemsley and Friston exemplify a popular approach, proposing that a functional disconnection in neural circuitry (perhaps between frontal and temporal regions) leads to a failure in the constraining impact of context upon the processing of perceptual detail. Gestalt perception is disturbed, leaving the subject at the mercy of being captured by incidental details; their sensory input becomes interrogated against a backdrop of now inappropriate frames of references leading to disturbances in perception of significance. Or we can consider the interesting approach of Frith who proposes that a disturbance in corollary discharge leads to passivity experiences and the associated delusions.

Psychiatrists, especially psychoanalytically minded psychiatrists, have also given us an account of specifically delusional thinking. What, they ask, is the character of the mental functioning at work when delusions crystallise? Inspiration has primarily been taken from Lucien Lévy-Bruhl's notion of 'pre-symbolic magic participations' (symbolic equations / condensations). Symbolism proper proceeds along lines governed by convention, and is in the service of communication. With pre-symbolic participations however the subject does not distinguish between the symbol and the symbolised, and the pseudo-symbols are not formed primarily to communicate; instead, they are substitutes produced via displacement (cf Agnes Petocz and Marguerite Sechehaye).

Hanna Segal (1991) suggests that there are ‘two kinds of symbol-formation and symbolic function. In one, which I have called symbolic equation, and which underlies schizophrenic concrete thinking, the symbol is so equated with the object symbolised that the two are felt to be identical. A violin is a penis; playing the violin is masturbating and therefore not to be done in public. In … true symbolism or symbolic representation, the symbol represents the object but is not entirely equated with it.’


Sechehaye: 'Dominique, a young schizophrenic just brought to the clinic, begged her parents 'to restore its head to my doll; it is broken and it will be more and more mangled; you must take it home; it is the only way to set things right again.' (62-3)

The analysts also describe the ways in which projection, projective identification and splitting lead to the creation of delusional perceptions and paranoid thoughts. Here the key idea is that what would once have been located inside the self is now located outside. (Whether this is due to transitivistic confusion (Bleuler) or to motivated projection (Klein) or to both is unclear - cf later.) Thus paranoia has been theorised as due to a boomerang effect of intolerable aspects of the self projected out into the environment.


The psychoanalytic characterisation of the nature of delusional thinking shows the distinctive type of thinking that it is. This is different from the cognitive psychological account of delusion as a breakdown of belief formation. The delusional mind as the psychoanalyst characterises it is a mind in a particular ('primitive') mode or form of functioning. It is not a matter of there being a failure in certain of the reasoning procedures - 'rational mechanisms' as it were - by which beliefs are normally formed. 

c) Autism / Forms of Mindedness / Disembeddedness

But what is the kind of mind that embeds and informs such delusional thinking? One of Bleuler's 4 'A's characteristic of schizophrenia was autism (the others being association, affect, and ambivalence). The schizophrenic mind is autistic, he claimed - meaning that it operates in its own sphere, disengaged from reality contact, taking its own phantasms for realities. R D Laing writes of one of his early patients (Divided Self p. 221): ‘Reality did not cast its shadow or its light over any wish or fear.’ ‘Every wish met with instantaneous phantom fulfilment and every dread likewise instantaneously came to pass in a phantom way.’ Psychoanalytic authors today, by the way, tend to talk not of autism but of a 'psychotic part of the mind'.

The clinicians who have best elaborated the character of schizophrenic autism are the phenomenologists (e.g. Blankenbourg, Minkowski, Bovet, Parnas, Sass, Stanghellini, Mishara, Fuchs, Gallagher, Maggini, Raballo). A key feature of their re-theorisation of the autistic vulnerability in schizophrenia is their recasting of it as due to a disturbed pre-reflective attunement to the world, especially to the world of others. 

A key aspect of phenomenological theorisations of delusion is their insistence that delusion be understood in the context of a radical transformation of the subject's being-in-the-world (and not, say, merely in terms of a disturbance in the processes by which beliefs are formed or maintained). They are rooted in different forms of being-in-the-world and may also refer to these different 'worlds' (which explains why they are sometimes not connected with action in the real world in the way one might have anticipated (double bookkeeping etc.)).




World: The automatic habitual character of immersed perceptuo-motor activity that subtends the stable experience of a separated self-in-relation-to-a-world is compromised. The body subject struggles to automatically coordinate, as a living invisible centre, the shifting frames of reference around it. Stable perceptual meaning begins to break down (i.e. delusional atmosphere). 'Something is going on'. The world may appear unreal (derealisation, depersonalisation), a domain of images, pasteboard. As Sass suggests, contrary to the psychoanalytic idea that delusion is a result of the hypercathexis of the imagination (mistaking the imaginary for the real), the real 'trouble generateur' is the loss of automatic certainty which denatures the real rendering it akin to the imaginary. Unable to maintain itself as an invisible centre coordinating diverse frames of reference, and depleted by the terror of living in this disintegrating world (trema), the lived body switches to a new form of intentionality in which the body itself is taken as the frame of reference. The result is that everything experienced seems to relate to the self: this is the autocentric polarisation of the intentional field - (anastrophe) - which provides the fertile soil in which self-referential (paranoid) delusions grow. Metaphysical delusions, abnormal attributions of meaning - apophany - thematise this reshaping of the world. (Cf Conrad.)

Others:  The delusional subject's inability to smoothly coordinate perceptuo-motor frames of reference is particularly acute in the interpersonal domain, so that the subject struggles to locate agency and potency proportionately to self and other. The delusional results which thematise this are delusions of omnipotent power or of enfeebled persecution or nothingness.
Delusions not infrequently emblematise the disturbed reality relation. Thus Sechehaye's patient Renee's Wahnstimmung was expressed as 'A great disaster is on its way; the earth will shake to its foundations and collapse with a horrible noise.' Later she lamented 'The water, the water is rising constantly and coering the world in liquid, icy sheets. Soon there will be nothing but water, a desert of ice water. How can I escape? Help, please, save me'. ... Renee wailed for hours at a time as she imagined herself watching real catastrophes: 'Whole cities are crashing, avalanches of rock come tumbling down with a noise like thunder. Only crumbling, yawning holes, chaos and destruction remain.' 

d) Motivational Dynamics 


Improving self-esteem: Grandiose delusions may function - and the patient may be motivated to form them - to increase self-esteem. 


John Strauss (1991): ‘a young woman who has been severely delusional has not been particularly well educated or had much psychological treatment. She was telling me in one interview how her feelings that people were controlling her were much better now than they had been before. I asked her why, and she said that was easy, that she did not have to be paranoid any more, since she felt so much better about herself.’ 

Roberts (1991) had a patient who had believed he was the Messiah said ‘I liked to imagine it because I felt so useless without it… I still feel inadequate now – it’s as though I don’t know anything. I always felt everything I said was worthless, but as Jesus everything I said was important – it came from God. … I just want to hide away, I don’t feel able to cope with people … I always feel lonely, I don’t know what to say.’ Delusion as wish-fulfilling phantasy. 

Jung's patient: The patient was a poor dressmaker who ‘fell ill in 1886 in her 39th year – on the threshold of the age when so many dreams are brought to naught’. She has sat ‘like an “imbecile” for twenty years in her workroom, mechanically darning her linen and occasionally mumbling a few meaningless phrases which nobody had been able to understand. Jung records the following fixed delusions: At night the spinal marrow is torn out of her; pains in the back are caused by substances going through the walls covered with magnetism. The monopoly establishes the pains that do not stick in the body and do not fly about in the air. Extracts are made by an inhalation of chemistry and legions perish of death by suffocation. … The patient styled herself “The Banknote Monopoly, Queen of the Orphans, Proprietress of Burghölzli Asylum.’ ‘Naples and I must supply the whole world with macaroni’. … She was Socrates…. ‘I am the finest professorship and the finest world of art.’ ‘I am the Lorelei … Switzerland … a crane … Schiller’s Bell … Hufeland … the master-key …’ She is the owner of a distant island with silver mines, ‘the mightiest silver island in the world’… the ‘greatest orator’ possessing the ‘highest eloquence’. … she is not only the honoured earthly queens Mary Stuart and Louise of Prussia, she is also the Queen of Heaven, the Mother of God, and at the same time the Godhead. … she chose three husbands from the best families in the town and her fourth was the Emperor Francis. From these marriages sprouted two phantom children, a little boy and a little girl. (Jung, 1907/1991, pp. 173-177). 

Sechehaye: delusions as positive wish-fulfilling substitutes for disappointments. 69 ‘a young man, neglected by his mother because of a congenital physical malformation, who sought tenderness in young girls. Unfortunately, the rejection of his tentative amorous advances reactivated the initial privation and precipitated a psychosis. After a short agitated phase, he fell into a long dream-like state offering everything hitherto denied by reality. During a period of improvement, questioning revealed that he had at last found happiness, as he believed himself the son of a powerful royal couple who adored him and granted his every request. He was an Arabian prince, handsome and fabulously rich, living in a harem surrounded by a bevy of women, each more beautiful than the other, who fought for his favour. His conquests were numberless; he was a veritable Don Juan. The shame, the bitterness and distress of his mother’s neglect and his amorous disappointments had disappeared, to be replaced by an exuberance of power and pride, unhappily at the expense of mental equilibrium.’

Renee’s compensatory phantasies: (p. 69 of ‘a new psychotherapy in schizophrenia’) ‘She imagined herself queen of Tibet but… she had neither court nor palace nor riches at her disposal. To be queen of Tibet was to live alone in a distant land, away from everyone. Yet this poor fantasy compensated for her intolerable insecurity, realizing her desire to return to her infancy when her parents lived in material comfort and especially to the maternal body. “Tibet”, she explained, “is the loneliest, most inaccessible country in the world. Entrance is forbidden. Once one leaves there is no going back. But I succeeded because I am nine centuries old [the nine months of the gestation period]. I forced the doors and now I am protected by high walls and hidden from the eyes of everyone. … I am absolutely alone. No one may enter; it is closed on all sides except for a narrow and dangerous pass obstructed by prickly trees.” To one accustomed to psychoanalytic symbolism, this response is obvious, referring to the anatomy of the female body.’ symbolic translations of frustrated fundamental needs.

Reducing dissonance: Delusions thematise and thereby may function to reduce dissonance - relief through rationalisation; a return of a sense of meaning (trema resolving into apophany). Freud: delusion formation as restorative: ‘like a patch where originally a rent had appeared in the ego’s relation to the external world.’ (Freud 1924 p. 151.: Neurosis and psychosis. In SE 19 (149-153)). Self-functioning may be restored as fragmentation is no longer experienced within the self. Arieti (1964): ‘indefinite feelings become finite, the imperceptible becomes perceptible, the vague menace is transformed into a specific threat… the sense of suspiciousness becomes the conviction… Things that appear confusing and obscure have a meaning and purpose.’

Projection: To the extent that transitivism (attribution to others of aspects of self) is dynamically driven (intolerable aspects of self-representation are projected into the other-representation), projection (and splitting and projective identification) are intelligible teleologically as defensive functions. Of course it could be that non-dynamically formed self-other confusions provide the perfect terrain for projection to take root - the dynamic defense exploiting the non-dynamically-generated disturbance in the stable enaction of self-in-relation-to-other.


Bringing a), b), c) and d) Together


To recap: The account of specifically schizophrenic delusion offered to us by psychodynamic psychiatry involves the following four elements:

a. The idea that delusions are not best understood as beliefs expressing and aiming at the everyday consensual world.

b. The idea that they instead arise in, and reference, an 'autistic' or 'psychotic' part of the mind. They speak from and about a form of mental functioning which is not grounded in everyday practical reality-contact, but which instead fuses wish or fear into the fabric of the new world of meaning inhabited by the delusional subject. That delusions sometimes simply thematise this world. 

c. That in this domain the primary processes rule, such that quasi-metaphorical, quasi-symbolic links are made instead of representational thought which keeps subject and object separate. 

d. That delusions can be motivated - they may express the phantastic meeting of needs - for love, nurture, recognition, integrity, self-esteem, power, nurture.

The psychoanalytic understanding of delusion brings these four elements together: The patient, in an altered state of mind (in which reality contact is lost), is motivated to form delusional beliefs (by the need to bind anxiety, to symbolise their emotional distress, or to wish-fulfillingly phantasise the meeting of as yet unmet primary needs, or to disavow painful or shameful feelings), and symbolic equations and projection are, in this state of mind, the means by which this can happens. In particular, the symbolic equations allow the mind to both avow (express in modified form) and disavow (not straightforwardly acknowledge) its intolerable emotions and needs 

For example, Sechehaye talks p. 72 of how ‘The constant intervention of defensive factors rarely permits meeting the direct expression of the frustrated need. Among the numerous schizophrenic signs, however, certain symbolizations do reveal the demands, the pleas, and the disguised attempts to obtain assuagement of a disappointed vital desire.’ ‘The schizophrenic finds the possibilities of expressing his fundamental need most readily in such archaic modes of expression as regression, progression onto allowed models ... and pre-symbolic magic participation where the symbol is confused with the symbolized object. … [T]he need’s symptoms are displayed under two different guises: a positive one, the desire for satisfaction, and a negative one, the anxiety reproducing the initial trauma. The symbols on which the patient projects his affects present one or the other of these aspects and often both together. This double projection was striking in Renee’s case. At the beginning of the regressive phase she regularly projected her wish to return to the nursling stage on a rag doll she called “Moses”. “Moses” she said “doesn’t have to eat. He is always fed and it isn’t necessary to give him anything”, while about her monkey she complained fearfully “The little monkey is going to die of hunger; no one is giving him anything to eat”. She herself had no right to eat; the “system”, the “punishment machine”, forbade it. If she succumbed to the temptation to eat, the “system” would transform her into a starving cat. Here the difference is at once clear between the spontaneous expression of the need (the monkey is hungry, Moses is always nourished) and the reaction to frustrated need (the system forbids me to eat; I will be transformed into a starving cat). The direct expression of the need adopts a primitive, archaic form, utilizing the elementary process of projection, while the reaction to frustration takes a more elaborated, more intellectualized form due to the intervention of ego defense mechanisms.’ 


Ordinary and Extraordinary Understanding

Let's return to where we started  with the question of the unintelligibility of schizophrenic delusion. During this talk I have presented 3 different forms of understanding which we can bring to bear on schizophrenic delusion. These are the phenomenological (grasping different disturbances of being-in-the-world and seeing how delusions emerge from these), the causal (for example the operation of primary processes), and the dynamic (the contribution of defenses to the formation of delusions). What I want to point to here is that:

a. None of these make it the case that the delusion is intelligible as beliefs are ordinarily intelligible. To understand the causal forces and the existential situations from and in which beliefs emerge is not at all to grasp them as intrinsically intelligible ways of aligning oneself to the good, the true and the rational. Schizophrenic delusions are the products of a mind which, in its delusionality, is disconnected from the real and the norms of socially and rationally intelligible function. They are, then, precisely not intelligible as ordinary beliefs are intelligible.

(It might be said: Well, both delusions and everyday 'theories' serve to reduce dissonance by bringing order to experience. However ordinary theories primarily serve a truth-seeking function; their good psychological effects are secondary to this; they are therefore not simply rationalisations. Making ourselves feel better and genuinely understanding something are, clearly, two separate things!)

b.  Furthermore, if a belief is intelligible in the ordinary way we do, I suggest, have little business in offering phenomenological or causal or dynamic explanations of it. The kinds of understanding we can mobilise regarding delusions are in fact antithetical to the kinds of understanding involved in everyday sense-making.

c. The view that psychological understanding is a way of welcoming the delusional subject back into the fold of intelligible humanity is deeply misguided. First, psychological forms of understanding are needed precisely when rational intelligibility breaks down. Delusions constitute, one might say, not rationally intelligible responses, but rather psychological reactions, to situations and predicaments. Second, it encourages us to overlook the ways in which the delusional person is suffering - not merely from painful thoughts and feelings, but from terrifying fragmentations of selfhood which at times challenge their very standing as en-worlded subjects. The cost of holding out the promise of overturning Jaspers' allegedly pessimistic doctrine of ununderstandability is that one misses the sometimes shattering music at the heart of the schizophrenic condition and trivialises the depths of their distress.