Sunday, 1 November 2015

the symbolic meaning of delusional thought

First bash at a chapter in a book I'm very slowly writing on the intelligibility of schizophrenic thought...

a. Introduction

The upshot of the critical investigation of cognitive theories of delusion in chapter 1 was that, regardless of the possible reasoning or perceptual deficits of schizophrenic subjects, meaning cannot be usefully retrieved from their delusional discourse by treating the latter as expressing intelligible mistakes of reasoning or perceptual judgement. Schizophrenic persons may suffer at times from aberrant perception or faulty reasoning but, as Jaspers insisted, what is explained in terms of such failures is not delusion but merely erroneous belief. Delusion proper implicates a far more fundamental disturbance in what we call ‘reality contact’ than the accumulation of hallucinations and/or errors of judgement: in fact, one might say, an intelligible description of someone as, regarding some subject matter, truly capable of ‘making mistakes’ about it presupposes, rather than contradicts the assumption, that they are here fundamentally ‘in touch with reality’.

A suggestion frequently made in the psychiatric and psychological literature is that delusions can be understood if we treat them as enjoying that form of intelligibility manifest by metaphors or symbols. The appeal of the idea is clear: that we can find meaning in psychotic thought by ‘decoding’ it – by looking beyond its apparent surface meaninglessness to a meaning buried within. ‘Our task in everyday psychiatry is to decipher the meaning of these [disguised memory fragments]. This is comparable to solving crossword puzzle clues…’ is how one psychiatrist put it (using an uncharacteristically glib simile) (Lucas, 2009, p. 307). The underlying aspiration here is, by thus ‘decoding’ the psychotic subject’s utterances, to bring him or her back within the fold of intelligible humanity.

In what follows I first explore the idea that delusions can be understood along the lines of metaphors – i.e. as attempts to communicate truths using non-literal language. This approach however soon runs into difficulties, difficulties that necessitate the making of two fundamental distinctions. The first is between such symbolism as presupposes a mind capable of thinking about some matter yet which intentionally makes play across conceptual categories to communicative ends (i.e. metaphor – symbolism as an intentional rhetorical act), and the different form of symbolism of a mind not yet capable of tolerating representational thought about some matter, where the conceptual miscegenations it manifests are symptomatic of this inability (i.e. psychological symbolism – symbolism as a psychological process). The second is between two uses of psychological symbolism. One of these has to do with the nascent capacity to represent the facts in the progressive service of reality contact and acknowledgement of and accommodation to the sometime painful absence of what is desired (in psychoanalysis this is called either ‘symbolisation’ or ‘thinking’). The other has to do with the regressive denial of need and the provision of substitutive, imaginary, satisfaction for unmet needs (‘wish-fulfilment’ and delusion). Quite different forms of understanding and intelligibility are applicable to metaphor and psychological symbolism, and a central aim of this chapter is to make these clear so that explanations of the latter, primarily provided by psychoanalysis, will not be judged as deficient by those who have available to them only such standards as are relevant to the assessment of the former.

To understand psychological symbolism it is essential to appreciate the frame of mind in which it takes place. This is especially so when it comes to grasping the regressive, wish-fulfilling, reality-denying uses of symbolism as makes for much schizophrenic delusion. Without appreciating how different the psychotic mode is from that which constitutes reality contact, delusions may hastily and unhelpfully get treated (by cognitive scientists, for example) as if they were essentially mistaken uncommon beliefs, and the quite distinct intelligibility they do enjoy is overlooked whilst a form of everyday meaning is ascribed to them that, precisely, they do not in fact enjoy. The distinction here is between the recovery of speaker’s meaning in a mind enjoying reality contact versus the appreciation of the emotional and motivational causes of delusional thought in a mind partly insulated from reality. This insulation takes the form of psychic retreats (Steiner 1993) or, in the term’s original sense, autism (Bleuler, 1911). A key contention of this chapter is that it is only once the distinction, which receives its fullest treatment from phenomenological psychiatry, between autism and reality contact is appreciated, that the distinctive intelligibility of psychological symbolism, as elaborated by psychoanalytical psychology, can be reflectively understood. (A fuller explication of autism must however wait until chapter 4.) The merits of taking a psychoanalytical approach – an approach that understands the forms of mental disturbance as resulting from motivated attempts to manage intolerable emotional pain – are several. They extend considerably beyond the formulation of delusion in terms of symbolism, inter alia into theories of paranoia, bizarre delusions, delusional perception and mania in terms of ‘splitting’, ‘projection’, a failure of ‘alpha function’ and ‘omnipotence’.  But even when we restrict ourselves (as in this chapter) to matters of symbolism, the merits of a psychoanalytic over a cognitive approach include the ability to account for the typical (paranoid, megalomaniacal, erotic) forms of delusional belief, and also to explain the relation of psychotic experience to psychotic thought without falling back on the cognitivist’s implausible model of the latter as resulting from attempts to make rational sense of the former.

b. Delusion as Metaphor

We’ve all had the experience of being baffled by what someone says only to realise that we had taken literally what needed to be taken metaphorically. Perhaps – so the thought goes – we can find relief from our bafflement by delusions in the same way. It is important then that we first get clear on what is meant by a metaphor; two essential aspects bear mention. First, metaphor involves a mapping across conceptual domains, from ‘source’ (e.g. weather) to ‘target’ (e.g. emotional expression) domains (‘she gave him a frosty smile’), and often involves the use of physical state and event terms to betoken psychological and relational properties. Second, the concept of metaphor belongs to the ars rhetorica: i.e. it essentially describes a technique used by a speaker or author to encourage a particular understanding of what is being talked about – e.g. to enhance the listener’s grasp of speaker’s meaning. Thus we may hear of someone uncritically accepting what someone else says, but by using gustatory metaphors - ‘He had her eating out of the palm of his hand’; ‘She was lapping up / swallowing everything he said’ – we are provided with a more potent sense of the power relations at play, of how the eager listener’s loss of self-possession and willing neediness figures into the readiness with which what is asserted takes root in her mind.

An important precondition for the intelligible ascription to a speaker of metaphoric talk is that he grasp the distinction between source and target domains. If he thought that to swallow or lap something up always meant to accept it uncritically, and had no understanding of its literal gustatory sense, then we should not yet talk of him as speaking metaphorically. Not only does the concept of the metaphorical presuppose the concept of the literal to which it is internally (through contrastive application) related, but the idea of someone speaking metaphorically requires that the speaker can acknowledge that he is not here to be taken literally.

As applied to the understanding of delusion, the promise of the concept of metaphor is that, whilst delusional utterances remain unintelligible as literal assertions, they may perhaps yet be grasped if interpreted as metaphorical. Consider the following: before I trained as a psychologist an eccentric woman who visited the drop-in centre where I worked in Oxford told me that she had recently been released from Belsen (the German concentration camp which had been closed for 60 years). I was confused but, from what she was saying, I understood that she had probably been discharged from the local psychiatric hospital. Naïve to the nature of schizophrenic delusion, and attempting to retrieve meaning in her utterance, I therefore interpreted it as a metaphor and offered her a reworking into a simile: ‘Ah, you mean, being at the Warneford was like being at Belsen?’

What was wrong with my response is what is wrong with a theory of delusion as metaphor. The woman looked baffled and, now a little disturbed, said with hesitation: ‘It was Belsen’ – before changing the subject. Whilst taking what she said as a metaphor would be an obvious avenue for retrieving sense in it, that sense is yet dependent on her intending her statement as metaphor. Without that intention the sense-recovery operation fails since the disturbance in intelligibility has just, as it were, been shunted from her failure to advertise, to her failure to appreciate, that she is not to be taken literally. What we really encounter here is not a speaker who deploys the conceptual resources of the metaphorical and the literal to map from one domain to the other, but rather a speaker whose thought and utterance simply collapses the source (Belsen) and target (Warneford) domains.

Two rescue strategies now present themselves (these are taken from Rhodes & Jakes, 2004). The first locates the making of the metaphor at a time before the psychotic collapse of the source and target domains sets in. To borrow a clinical example taken from Rhodes & Jakes (2004), a patient at first seemed to use a concept of devil possession in a non-literal way – perhaps to describe her experience of being out of mental control - but then became psychotic at which point the metaphor collapsed into the literal locution. In this approach the decoding or retrieval it is incumbent on us to do involves the back-extrapolation to a time before delusionality became ascendant: Whilst she may not now be saying something intelligibly taken as metaphor, what is said yet carries the trace of a metaphor she once used in her own thinking. We thereby retrieve a genuine meaning in her pre-psychotic life.

One difficulty with this proposal is that, regardless of its adequacy in meeting its own ends, it does not of course help us with our end of retrieving the delusional speaker’s meaning; in fact it asserts that what is now being said is not now to be found intelligible as metaphor. The second is that it is hard to evaluate since it postulates a pre-psychotic state of a respectably metaphoric use of the notion later crystallised in the delusion – and this state and use will often be irretrievable in anamnesis. Furthermore many delusions involve figurations that do not precede the psychotic state (Rhodes & Jakes, 2004). This is particularly the case when we have to do with the delusional perception found in schizophrenia – i.e. when someone looking at the cross suddenly sees that he is Jesus, looking at the dog raise its leg sees that the Kaiser has a special message for her, etc. The principal objection is not to the content but to the scope of the rescued metaphor theory: that in saving intelligibility by invoking pre-delusional metaphor use, the theory does not yet help us grasp a sense in which delusional figurations can themselves, whether or not historically preceded by metaphoric thinking, be understood symbolically. It also provides no understanding of why the patient is here so selectively disturbed in her grasp of the distinction between the metaphoric and the literal.

The second rescue strategy follows Lakoff & Johnson (1980) in removing the concept of metaphor from the home ground of intentional human agency. No longer treated as intentional human action it becomes instead a merely causally specified psychological process. Since we are now no longer to appeal to what someone intends in making their utterance we must also forego specifying what counts here as ‘source’ and what as ‘target’ in terms of the intention of the speaker; perhaps these become specified post hoc by the theorist. This metaphorical use of the concept of metaphor in effect reduces all metaphor to the level of the dead metaphor, the life provided by the ars rhetorica having been taken from it. But whilst there is nothing wrong with consciously using the concept in this way, we must now guard against unwittingly attempting to both have and eat our epistemic cake. That is, we must not imagine that treating delusional utterance as metaphor in this merely causal rather than intentional sense allows us to still retrieve speaker’s meaning from it. For when we consider what it is for someone who says ‘I have just been in Belsen’ to be referring to a stay in a psychiatric hospital they found dehumanising, terrifying and soul-destroying - rather than to have, for example, made a mistake about its name – we make essential appeal to her intention-in-utterance (she meant to describe how awful it was there), to the clarifications she would offer if pressed (‘I mean it was like…’), and to her assent to or dissent from clarifications offered (‘No I mean it was Belsen.’) As we will see below none of this means that what she says does not provide us with important information about her psychology, but it does mean that we cannot take what she says as meaningful in that sense of ‘meaningful’ which adverts to what she intends to communicate.

The hope of recovering a speaker’s symbolic meaning in delusional discourse simply through treating it as expressing metaphor fails. It fails because whilst promising to help us grasp a meaning for delusion it helps itself to the notion of an as-yet-unexplicated form of speaker’s meaning. If we are yet to find some sort of meaning in delusional discourse, we require some means other than a reference to speaker’s intention for distinguishing between what here counts as symbol and what as symbolised. Psychoanalysis provides this with its theory of psychological symbolism and its understanding of the motivational and emotional dynamics underlying the formation of psychological symbols. This will be described below, but first it is essential that we grasp something of the constitutive and embedding state of mind in which symbolism obtains.

c. Schizophrenic autism

Textbook definitions of delusion make it sound as if it were all simply a matter of stubbornly entertaining mistaken or impossible or atypical beliefs. But [cf ch 1] as Jaspers (1963, pp. 93ff) – who himself introduced such criteria – noted, to say this is but to provide a ‘superficial’, ‘vague’, merely ‘external’, and ‘incorrect’ account of the delusionality of delusion – which instead must be understood for what it is in terms of such deep alterations in the fabric of the personality (by ‘personality’ Jaspers means individual selfhood or personhood; he’s not referring to someone’s introversion or extroversion etc.) as ramify into the character of that personality’s meaningful experience of the world. These alterations were mysterious to Jaspers (p. 96: ‘a clear presentation is hardly possible with so alien a happening’), and much of the work of phenomenological psychiatrists since his time has been to elucidate them in a meaningful way (see ch. 4). Since the time of Bleuler (1911) this altered form of selfhood has been known as ‘autism’ – not to be confused with the developmental condition of ‘autistic spectrum disorders’ for which Leo Kanner redeployed the term in the 1940s.[1]

The Greek term ‘autós’ means ‘self’, and Bleuler’s use of the term refers to an inner retreat into the self away from the world:

The most severe schizophrenics, who have no more contact with the outside world, live in a world of their own. They have encased themselves with their desires and wishes (which they consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas; they have cut themselves off as much as possible from any contact with the external world. This detachment from reality, together with the relative predominance of the inner life, we term ‘autism’. (Bleuler, 1911/1950, p. 63)

He goes on to note (ibid, p. 63, note 19) that:

In essence the term, autism, designates in a positive way the same concept that Pierre Janet formulated negatively as “the loss of the sense of reality.” … [But the] sense of reality is not entirely lacking in the schizophrenic. It fails only in relation to matters threatening to contradict his complexes. Our relatively advanced hospital cases can very correctly comprehend and retain such detailed anamneses which turn out to be quite correct. In short, they show daily that they have not lost their sense of reality, but that this capacity is inhibited or falsified in certain connections…

Autism, then, involves a disconnection from reality and into a ‘world of one’s own’. But what this means is not easy to say; it is tempting – although also unhelpful to a project of critical reflection – to gloss this as ‘living in an imaginary world’, or as ‘imagining one’s wishes or fears fulfilled’, or to say that ‘delusional utterances refer not to our consensual reality but to the states and events of an inner private world’. Although such phrases are not exactly wrong, in truth they too – like the word ‘false’ in the phrase ‘delusions are false beliefs’ – carry a meaning special to their psychiatric context, a meaning which now needs reflective unpacking rather than assuming. Bleuler, not being a philosopher, is not going to help us with this. But nearly as soon as he introduces us to autism he does provide a clue in writing not about the different possible contents or rationality of thought but of its different possible forms:

realistic and autistic thinking which exist side by side in the same patient. In realistic thinking the patient orients himself quite well in time and space. He adjusts his actions to reality insofar as they appear normal. The autistic thinking [however] is the source of the delusions, of the crude offenses against logic and propriety, and all the other pathological symptoms. The two forms of thought are often fairly well separated so that the patient is able at times to think completely autistically and at other times completely normally. (67).

We get our best clue as to the nature of this distinctive form of thought by reflecting on what is wrong with formulae like ‘living in an imaginary world’. Thus sometimes when we talk of (i) ‘imagining’ we mean ‘wrongly envisaging or expecting’, a passive and dispositional use of the term not far removed from that of ‘(usually falsely) believing’. This sense of ‘imagine’ helps us not at all here, since it does nothing to help us achieve what we want from a concept of ‘autism’; definitions drawing on this sense of ‘imagine’ effectively ignore or presuppose – rather than establish – the sense of the delusionality of psychotic thought. To see this, consider how Bleuler often gives examples of what he calls ‘double-entry bookkeeping’ to explicate the character of autistic thought. In these examples a patient professes one attitude in the delusional mode (I am the king of Denmark) whilst at the same time manifesting dispositions that signal reality contact (it is my job to scrub the kitchen in the hospital). It is here just this absence of the normal dispositions in which false belief is manifest which marks delusion as such and which accordingly makes such a concept of (i) imagining in-apt to its explication.

At other times we mean by ‘imagining’ not a passive expectation but rather (ii) an intentional action, as when I intentionally ‘picture something in my mind’s eye’. This is the most distinctive and potent sense of ‘imagining’ we possess, and is explored at length by Sartre and Ryle. It however is essentially connected with my understanding of the imagined object’s absence: I am, that is, precisely not at such times trying to see something but rather to visualise something that I understand is not there to be seen. Here therefore imagination presupposes – in my grasp of the object’s absence – intact reality contact, and this too makes it in-apt for present purposes – since delusions are believed in by delusional subjects.

We get closer to an apt sense of ‘imagining’ when we consider (iii) those uses of the term that are synonymous with ‘dreaming’ or ‘fantasising’. When (non-lucidly) dreaming we are not aware that we are doing so – we are lost to the dream, so to speak, and accordingly are not in touch with reality; such imagining is not intentional action but unintentional activity. (It is not insignificant that psychosis has often been described as a ‘waking dream’.) Yet this sense does not collapse us back into the first dispositional sense of ‘imagine’ since when daydreaming we do not at such times believe that what we daydream is or isn’t the case; the whole point of this mode of thought is, after all, that ‘reality testing’ is put off-line.[2]

 In this (iii) sense of ‘imagine’, we meet not with a retreat into imagination qua visualisation, but rather with a breakdown in the distinction between either visualising or envisaging and veridically perceiving or believing. As Freud describes, ‘an uncanny effect is often and easily produced by effacing the distinction between imagination and reality’ (1919 p. 396). What makes for the distinctive nature of (ii) imagination as a non-reality-oriented intentional action, i.e. that it yet preserves reality contact, is what is definitively lost in this conception of (iii) imagination as dreaming.

On this understanding autism amounts not to a retreat into active imagination but rather into a state of mind in which the distinction between imagining and reality contact is selectively effaced. The sensori-motor cycles which embed us in our worlds and which form the causally-constraining foundation of reality-oriented thought are disengaged here. Instead the shape taken by this dreamlike thought becomes governed by inner association: one dream image sparking another, the shape of associative pathways primed by recency, emotional valency, habitual preoccupations, self-soothing potency, etc. The person in an autistic state of mind is not so much, for example, actively imagining their wishes fulfilled. Rather they are indulging or suffering a form of thought in which the distinction between wish or fear and its fulfilment is effaced. The form of autistic thought does not therefore amount to an unambiguous triumph of the imagination over the real. If we are to speak of triumph here it is one of a triumph of the need to manage intolerable mental pain over the integrity of both imagination and reality contact. Laing (Div Self, p. *) describes well how autistic thought is the very erosion of both inner and outer experience in his patient Julie:

‘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. Thus she could be anyone, anywhere, anytime. ‘I’m Rita Hayworth, I’m Joan Blondell. I’m a Royal Queen. My royal name is Julianne.’ ‘She’s self-sufficient,’ she told me. ‘She’s the self-possessed.’ But this self-possession was double-edged. It had also its dark side. She was a girl ‘possessed’ by the phantom of her own being. Her self had no freedom, autonomy, or power in the real world. Since she was anyone she cared to mention, she was no one.’ ‘I’m the prairie. She’s a ruined city.’ ‘She’s the ghost of the weed garden.’

[The hungry infant who, in the absence of breast or bottle makes suckling gestures and appears calmer, is no better described as satisfying their desire for food through a fantasy of feeding than they are as engaging in activity which dismantles their desire. (Jim Hopkins’ term ‘pacification’ works much better than ‘fulfilment’ here.)] The psychotic does not so much fool himself that his desires are fulfilled – as enter into a state of mind in which both the desire and his appreciation of the object in its absence is trashed.

d. Metaphor, Imagination, and the Pre/Trans Fallacy

Delusions have typically been understood either as false (and atypical and stubbornly maintained) beliefs (DSM-5), or as derivations of metaphorical thought (Rhodes & Jakes 2004) or imaginings mistaken by the delusional subject for bona fide literal beliefs (Currie 2002). The approach taken here is rather different: delusional thoughts must be understood as such in terms of that alteration in the personality which makes for the autistic enclave wherein such thoughts obtain. And autism is not to be understood as a retreat from reality contact to imagination, but as a local collapse, or defect in the formation, of the constituting oppositionality of these two modes of thought. To make clear the difference between the current approach and cognitive psychological approaches it will help us to have an error theory of the latter.

When reality-testing (the capacity to perceive and understand independent reality as independent) is insecure or fragile – as it may well be in infancy for example – there is as yet little meaningful distinction to be made, regarding the subject’s thought, between the metaphorical and the literal, imagination and perception, sacred and profane, playful and serious, wishing and doing, inner and outer, etc. To say this is not to make an epistemological observation about a subject’s ability to correctly apprehend the categorical nature of her own mental activity, but an ontological observation about the as-yet categorically inchoate nature of such activity itself. As a subject develops in her reality-testing she may more robustly be described as now believing and now imagining. Later on, as she develops even further and such categorical distinctions can be reliably and aptly applied, she may start to knowingly make play across the categories of the real and the imaginary, the inner and the outer, to make for more vivid and expressive (i.e. poetic) communication. Such pre- and trans- states may however superficially resemble one another and – and this is our error theory – psychological theorists may conflate them on this basis. This conflation has been dubbed the ‘pre/trans fallacy’ by Wilber (1982) who describes, for example, how Freud sometimes reductively deflates mystical ego-transcending states into the pre-ego states of infantile oceanic bliss, or how Jung can romantically and unrealistically inflate the pre-ego states of infancy and psychosis into those of ego-transcending mystical experience.

Applied to delusion the moral is that the use of a term that presupposes a collapse of target and source domains (pre) cannot be equated to a metaphorical use that depends on intentional play across the domains (trans). Only the latter provides the conditions for the retrieval of speaker’s meaning from the expression. Delusion may look superficially like either false belief or imagination, but this is only because none of these states involves veridical belief. We so habitually read one another against the tacit background assumption of reality-testing being in place that we find it hard to suspend such an attitude even in outré cases. Yet in the case of delusion and the autistic state of mind in which it obtains the distinction between the real and the imaginary has been deleteriously effaced. Such cases are to be distinguished either from misfiring efforts in the real (delusion as false belief) or cases of its artful suspension in the imaginary (metaphor, imagining). To add an extra level of sophistication to one’s account of delusion – suggesting it is the result of mistaking one’s own imaginings for beliefs (Currie 2002) – is to attempt to make good an error by compounding it further; what is required is not uncommonly sophisticated if awry epistemic self-relation, but simply degraded ontological self-constitution.

e. Psychological Symbolism

What remains is to trace the distinctive meaning of symbolism and the logical character of its apt comprehension when what we have to do with is schizophrenic delusional thought which of its nature necessarily obtains in an autistic state. What follows draws on the clearest theoretical explication we have of symbolism, namely the ‘Freudian Broad’ theory of symbolism of Petocz (1999 ch. 10), but in turn broadens it. Petocz’s theory is, in its exclusive focus on drive-based conflict and wish-fulfilling substitutive satisfaction as the motors of symbolism, rather more Freudian than Freud himself, and in what follows I consider also such uses of symbolism as facilitate accommodation to the pains of real life (to be called symbolisation) rather than merely promote their evasion. Jungian approaches to schizophrenic symbolism sometimes attribute more progressive purpose and meaning to the unconscious and its symbolic productions than is naturalistically plausible; Petocz’s drive-based Freudian account steers us away from this but, I suggest, errs in the opposite, regressive, direction by ignoring the use of symbolism in serious play to facilitate the tolerable knowing of one’s privations, wounds and losses. Segal’s distinction between ‘symbolic equation’ and ‘symbolism proper’ is another important contribution to the theory of psychotic symbolism. In what follows however I carve up the conceptual animal differently and call both of these ‘psychological symbolism’, and distinguish between progressive uses of it in the depressive mode (‘symbolism proper’) and regressive uses of it in the paranoid-schizoid mode (‘symbolic equation’).

Carl Jung was the first to apply the insights of psychoanalytical psychology to psychotic thought. Jung believed that delusions were the product of unconscious material breaking through the resistances against it into consciousness; that this material was expressed in ‘the language of the unconscious’; and that some of the outré forms taken by delusion resulted from those psychological processes - identical to Freud’s dream-work - of condensation, displacement, and negation by which the content and character of feelings and impulses could be simultaneously expressed yet smuggled past the resistances (Jung, 1914/1991 [on the importance of the uncs in psychopathology] p, 209). That delusion formation is so similar to dream formation is another reason why, from a psychoanalytical point of view, psychosis can be considered a waking dream.
Symbolisation here means the dream-work – the creation of a substitute image for a feeling that cannot be straightforwardly owned. Consider the following example from Jung’s time at the famous Swiss psychiatric hospital known as the Burghölzli (Jung 1907/1991); the patient is 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 asylum workroom, mechanically darning her linen and occasionally mumbling a few apparently meaningless phrases. Jung listens to her and discovers various fixed delusions (pp. 173-177) – amongst them that she is] ‘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.

The patient’s illness, lack of educational and marital and family success, etc. are devastating to her, and several of her delusions symbolically represent her desire to be free of such impediments. Many of her desires can find expression only because their character is greatly distorted – many are, for example, represented as fulfilled (she has money, is a professor, etc.) and hence as tolerable. At other times her delusions involve role-reversals: she is proprietress and not patient of the Burghölzli. In her autistic world her wishes are not separate from their realisations. To translate the delusional symbolism here is to track back the wishful fantasy to the intolerable thwarted desires from which it springs.

Another Burgölhzi clinician, Marguerite Sechehaye, later developed a theory of ‘symbolic realisation’ as the therapy for schizophrenic patients. (The therapy consisted in sensitively understanding the symbolic meaning of the patient’s delusions and then, rather than confronting the patient with her painfully unmet needs, first meeting the needs in symbolic form. The Autobiography of a Schizophrenic Girl, co-authored with her patient Renee (actually one Louisa Duess, who recovered and later became a psychoanalyst herself) describes this in moving detail.) Her works provide careful descriptions of her patients’ delusional wish-fulfilments [A New Psychotherapy in Schizophrenia 1956 p. 69], such as that of:

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. [note to self: sort out the original from my summaries in this]

Such examples might lead us to assume that symbolism is always a function of repression and substitutive satisfaction.[3] Certain extant frustrated drives and conflictual desires are too painful to be consciously entertained; they therefore are repressed, subject to displacement, then to a regressive substitutive gratification. This however misses the connection between psychological symbolism and a still more basic function we can call psychological symbolisation. The latter relates not to the substitutive wish-fulfilling satisfaction of extant desires, but rather to the condition of their initial structuration. The clearest example here is provided by play therapy: the child often cannot at first give form to certain latent fears and wishes; instead they spontaneously act out scenes with e.g. dolls which scenes the clinician can understand as expressive of their own immanent affect. The model here is not necessarily ‘It is not I who am angry with my father; it is my doll who is angry with his doll father’. It is rather one of an as-yet inarticulable ripening yet unpicked anger at father nevertheless finding its initial articulation in an analogue situation.

What makes for inarticulation in the first-person case need not here be understood solely in terms of repression, but rather and also in terms of an excessive proximity. Too closely caught up in a conjoint world of me-and-you, I cannot yet develop thought about or feeling toward you. Here I do not know enough of you in your otherness and me in my separateness to feel love for you in your goodness, or anger at you in your hurting of me, or guilt in my wronging of you. The emotions that constitute our object relations are achievements of individuation, that basic drive to differentiate from and thereby come into comprehending relation with the reality of others and of our situations. Such individuating is fraught, it may be shirked; affect may not be borne, and contact as opposed to fusion with reality may not be successful. Symbolisation is the process and motor of such dis-identification and differentiation: an inner movement of mind through which selfhood, otherness, and the thought that constitutes the relation between self and other become possible.

In practice the distinction between symbolism and symbolisation may be narrow. Difficulties in individuation will often result from inner conflict. Yet development contains imperatives other than conflict resolution, imperatives such as accommodation to loss, change, privation and difference. Whether or not we have to do with a symbolism that compounds reality-avoidance through the elaboration of autistic enclaves in which symbol and symbolised are equated (‘symbolic equations’ in Hanna Segal’s terms), or whether we have to do with a symbolism that facilitates a true emotional accommodation to reality through an act of serious play in which a template for individuation is first laid down in relation to analogue situations, may depend more on the surrounding interpersonal and intrapsychic context than on facts internal to the psychological processes.

Consider the following from the teenage hospitalised Renee/Duess (Sechehaye 1951); we hear Renee’s voice here; her psychoanalyst Sechehaye is ‘Mama’ (pp.71-79):

Mama brought me a gift – a little plush monkey of which I was at once afraid. When he had his arms up, I was anxious lest he hurt me; and then, he had a most shockingly unhappy expression. Oddly, at that very moment, I felt the impulse to strike myself. I realized full well that my own arms were delivering the blows, still I was sure the monkey was attacking me. Nonetheless I did not know that he was a symbol of myself, nor in any case should I have known what that meant.
I said to myself, “I am I and he is he and there is no relationship between us;” however the confusion as to who was who was complete. He had the same troubles as I and moreover he wanted to hurt me, to destroy me, and I dreaded him without holding it against him for I realized it was not his fault. …
The monkey was very unhappy because he had nothing to eat; everything was forbidden him except apples and spinach. So I went to the orchard to gather an apple or two from the tree; these I ate voraciously. In taking these apples, I had no sense of guilt for the tree was part of my country, the land of Tibet I called it, of which I was queen. …
Mama bought me pounds of magnificent apples. But I could not touch them, for I was allowed to eat only my own apples still attached to their Mama-tree. I should have liked so much to have Mama give me apples, real apples I called them.
But alas, Mama did not understand….
[Later, after a severe crisis, the following exchange takes place.] while in my heart I was outraged that Mama too wanted to force me to eat, my eyes fell to her bosom, and when she insisted, “But why don’t you want the apples I buy you?” I knew what I was yearning for so desperately and I was able to bring out, “Because the apples you buy are food for grown-ups and I want real apples, Mama’s apples, like those,” and I pointed to Mama’s breasts.
She got up at once, went to get a magnificent apple, cut a piece and gave it to me, saying, “Now, Mama is going to feed her little Renee. It is time to drink the good milk from Mama’s apples.” She put the piece in my mouth, and with my eyes closed, my head against her breast, I ate, or rather drank, my milk. A nameless felicity flowed into my heart. It was as though, suddenly, by magic, all my agony, the tempest which had shaken me a moment ago, had given place to a blissful calm; I thought of nothing, I discerned nothing, I revelled in my joy.

Here the monkey is a symbol for Renee – specifically for her infantile self and its unmet needs and hostile urges. Apples are symbols for Mama’s breasts; Renee’s inarticulable desire for the comfort of maternal feeding and care is displaced onto the monkey and apple symbols. Analyst and patient come to understand this together and Renee’s healing is set underway.[4] Is it the case that Renee had clear desires and feelings the owning and content of which had to be displaced onto the analogue objects, or instead that she is only able to give shape to such desires in the first place through such objects? It is neither evident which answer one should give nor that an answer must be given. The question is the same as that which asks whether an unconscious desire is extant yet unknown, or whether it is rather immanent, inchoate, potential? Empirical evidence – e.g. of reaction time differences, dispositions to particular perceptual distortions etc. – will not help us decide this conceptual question, since it does not tell us whether such evidence itself pertains to extant and merely unavowed affect or to a sub-affective disposition. In some cases we may be drawn in one, in others in another, direction. This conceptual question is supplemented by a theoretical question, which has to do with whether what we meet with here are the delusions of an attachment- and reality-shirking autism or the creative propositions of a tentative other- and reality-embracing accommodation to the facts of life. A delusion about apples becomes, in Sechehaye’s careful hands, a creative steppingstone to the comfortable owning of deep personal needs.

So far we have considered wish-fulfilment and the expression of needs as two forms [?] of symbolism lying behind schizophrenic thought. A third form concerns the bare fact of disturbed self-experience. The schizophrenic process of self-dissolution is terrifying, and is typically articulated in terms of either a bodily or an external situation – this is the ‘delusional atmosphere’ surrounding the incipient schizophrenic, an atmosphere that condenses out into those metaphysical delusions pathognomic of schizophrenia. Following Merleau-Ponty, Louis Sass [Phenomenology as Description and as Explanation: The Case of Schizophrenia. in Gallagher & Schmicking (eds) Handbook of Phenomenology and Cognitive Science] has described such delusions as expressing or emblematizing – expressing in a concrete form – the self-disturbance of the schizophrenic process. Classic examples are delusions of being controlled by an influencing machine; being constantly recorded by video cameras; of the world coming to an end; of a great flood of water sweeping everything away; of a great heat or cold suffusing everything. As Sechahaye writes (p.63 of the new psychotherapy book), such delusions represent ‘an alteration of the “being-in-the-world”; in other words, the condition of psychotic disintegration in the schizophrenic. … Kunz … declares “What is expressed in primary delusion is not related to complexes but to existence and its alterations. The delirium [the translator really means delusion] is a part of the very alteration of Dasein and is a particular expression of it.”’

The expressive depiction in the delusion of the state of self-disintegration often projects it outwards, as the prodromal terror (the ‘trema’) resolves (in the ‘apophany’) into a clearer delusional articulation. It is not hard to understand how, despite the terrifying situation that is depicted, the dual emblematization and projection yet serves an anxiolytic purpose. The first anxiolytic moment is the very symbolising of the psychotic process: the sufferer is no longer simply shaken to his core since he can begin to articulate this: the process of symbolising articulation is itself a process of disidentification – the creation of a non-trauma-ridden vantage from which the self’s trauma can be articulated. The second is the projection outwards: living in a world that is persecuting or about to collapse is terrifying but less so than being a self that is self-hating or collapsing. We see examples of both moments in Renee’s case: (p. 64): ‘Renee, at the beginning of her illness, complained of the “terrible fear” constricting her. But soon she lost consciousness of her own fear, projecting it outside. “It is the wind,” she said, “howling in anguish across the desolate steppes”; later, the wind, the messenger of a great calamity, portended the end of the world.’

f. The logic of the symbolic understanding of delusional content

It is common to understand the idea of psychological symbolism through discursive metaphors. Thus Petocz (1999) first distinguishes between conventional and non-conventional (i.e. psychological) symbolism as follows: ‘Non-conventional symbolism differs from language and conventional symbolism in that the non-conventional symbol is not used primarily to refer or to communicate. Rather, it is a substitute produced via displacement, and can be used normally or pathologically, consciously or unconsciously. It includes no just isolated entities, but actions, events, and complex combinations.’ (p. 232). (In the previous section I have questioned whether the products of symbolisation are always best understood in terms of substitutes produced via displacement.) However she then goes on to say, of non-conventional (psychological) symbolism, that ‘the theme of the symbol as defensive substitute produced via the conflict-repression-substitution ‘formula’ [is] central’. Petocz is speaking metaphorically here of production according to formulae, and so no fallacy is committed, as it would be if she were attempting to speak literally. But the quote still illustrates a perennial temptation, found mainly in Jungian thought – that mythology, imagistic thought, symbolism, fantasy, etc. form the ‘natural language of the unconscious’. In the Jungian project the metaphorical nature of this ‘language’, and therefore too of the different form of understanding that must be brought to bear on it, is typically left implicit. Such inexplicit metaphor is perhaps one reason for the temptation to construe delusion as metaphor. But what must in particular be acknowledged is the fact that there is, for delusion, no translation of what is said into what is intended, no communicational intent that serves to specify meaning, and in fact no speaker’s meaning (beyond what is actually said) to be recovered. The symbol does not here stand for the symbolised, at least not when ‘standing for’ is understood as doing communicational duty.

The duty done by psychological symbolism is not to the needs of conversants but rather, if we focus on symbolic substitution and emblematisation, to the anxiolytic needs of the delusional subject. The meaning of delusion understood as symbol is accordingly a function not of the individual intentions or social rules behind its deployment – for talk of deployment (and a fortiori of intentions and rules) is not apt here – but rather of the empathically graspable human intelligibility of that which it replaces or nascently articulates. The meaning of such symbols may be usefully compared to cases such as ‘smoke means fire’, ‘2 stripes on the pregnancy test means you’re pregnant’, ‘the bus being delayed means I will be late for work’, ‘a red sky at night means a dry day tomorrow’. Such ‘natural meaning’ (as Grice (****) calls it) is not simply a function of the causal relations involved (fire causing smoke etc.) but in particular of the prior significance to us of the upshot or cause of the signs of smoke, stripes, delays, red skies etc. Lateness, good weather, pregnancy and fire matter to us – and so the non-conventional indicators or signs of them now also possess a derivative meaning (unlike the infinity of other causes and upshots around about us which matter not a jot). Thus it may be that I’m caused to dream of violence by eating mustard before bedtime, but it would be odd to say that my murderous dreams mean or signify mustard – and this is because mustard is a condiment rather than a predicament. What it means to talk of something in a dream or of a delusional idea as symbolising such and such, or as having a ‘natural meaning’, is for it to advert to a cause that has its own significance as a human predicament. Delusional utterances have their symbolic meaning partly in virtue of the clue they give us as to the intolerable complexes of the delusional subject that throw them up – their conflicts of identity, their unmanageable loves and hates.

To understand delusional utterance, we might say, is not to understand what is intended by the delusional person, but rather to understand his psychology. To view a psychological perspective as straightforwardly allowing the recovery of human intelligibility in delusional discourse is in this respect naïve. For not only do we not thereby recover meaning in its rational intelligibility but, by looking to the speaker’s psychology, we go further and thereby preclude treating what is said as a rational expression of intention. Delusions possess us, but only the self-possessed can be rational; we suffer from delusions in a way which we cannot be said to suffer from rational beliefs regardless of the pain the latter cause us: delusions afflict, whereas rational beliefs are of, us.

Delusions obtain, of necessity, in an autistic enclave, and understanding this is the first step towards grasping what the form of understanding is that must be brought to bear on delusion. Autism, I have claimed, is defined by a disruption of reality-contact and the consequent collapsing of the imaginary into the real.[5] It is this collapse, and not any degree of falseness or lack of inferential probity, that makes for that deep form of irrationality we call delusion. But the delusional discourse of a schizophrenic subject does yet reveal him to us in his human intelligibility, if we have the ears to hear. We do not grasp what he is trying to tell us, but rather what he is trying not to tell himself. We hear not his rational intelligibility nor his communicational intent, but rather the strains of the pain driving the delusions’ formation. We understand the delusional symbolism when we understand what is causing the delusion formation and how it serves its anxiolytic purpose – its purpose of binding a terror that is shaking the self apart. (‘like a patch where originally a rent had appeared in the ego’s relation to the external world.’ (Freud 1924 p. 151).) The patch, the binding, is a quick fix – it is not part of the fabric of ‘secondary-process’ thought and understanding; it is not accommodative; it is for when the accommodative project of establishing reality-testing is unendurable. In this chapter on the symbolic understanding of delusion I have however also described cases of symbolisation as well as defensive symbolism. Such symbolisation involves a tentative step in putting a need or feeling into a verbal or pictorial or active form. Whether or not such a symbolisation becomes taken up into autistic world-avoiding delusion, or whether it becomes a transitional step towards accommodation to inner and outer reality, will depend on various intrapsychic factors – such as courage, integrity, ego capacity, amount of envy and hate. But it will also depend on interpersonal factors – in particular, on how it is received by the listener, on whether it can be understood and handled without the incurring of shame.[6]

To wrap up let's consider again the woman in the homeless shelter who told me she had just been liberated from Belsen. She found it hard to acknowledge that she had recently been so mad that she had to be sectioned. Having just been at the psychiatric hospital was, we can readily imagine, overwhelmingly shameful for her. She may also have found the hospital to be inhumane and degrading - perhaps because it sometimes was, and/or because she projected such qualities into it. She thereby came upon the delusional notion that she had been in Belsen, a terrible place in which one could be incarcerated not because of anything wrong one had done, but because of others taking a dislike to who one is. This is the patch over the rent in her ego - the 'solution' to the problem of her terror and shame. Now the shame of being in an institution is lessened - the problem lay in the prejudice of others not in the collapse of her mind. Now the cause of her sense of threat lies outside and not inside her mind. (Here lies the fragment of truth in the cognitivist's notion that delusions are attempts to 'explain experience': she has an experience of terror and confinement which is rationalised by reference to the idea of being in Belsen. If she were in touch with reality however no explanation would required: the fact is that she was terrifyingly insane and confined in in the Warneford psychiatric hospital. We do not recover meaning in her delusion by seeing it as an attempt to explain or render intelligible or make sense of her experience, but rather as an attempt to provide a comforting illusion of sense - comforting merely in terms of its affective congruence with the unforgettable terror.) Belsen, here, is a psychological symbol of the Warneford. In understanding this we grasp something of the cause of the delusion: the displacement, the motivating drive. In understanding this we do not retrieve what she is trying to tell us, but rather what she is trying not to tell herself. But whilst we do not recover meaning in her talk we do yet recover something of her humanity that has become obscured to her: we understand her in her very human struggles to be a self-possessed subject, we can see why she is motivated to form delusions, see something of the emotional pressures she is labouring under. When thinking of whether the psychological symbol of Belsen functions as a symbolic equation that merely substitutes for healthy reality contact, or whether it is a stepping stone of symbolisation towards accommodation to the painful emotional facts, much will depend not merely on her - but on how what she says is received and treated by us.   

[1] Psychoanalysts (Lucas, 2009; Grotstein, 2009, ch. 6; Jackson & Williams, 1994) often follow Bion (1957) instead of Bleuler and refer to ‘psychotic and non-psychotic’, rather than ‘autistic and reality-oriented’, parts of the personality. However the different terminology ought not to lead us to the mistaken view that the ‘concept of psychotic and non-psychotic parts of the personality in the individual, introduced by Bion, provided a new perspective to the understanding of psychosis’ (Jackson & Williams, 1994, p. 196); the distinction pre-dates Bion by a good 50 years.

[2] ‘Reality testing’ is not to be confused with hypothesis testing. Hypothesis testing presupposes contact with reality – when we test mere hypotheses we enjoy basic reality contact and are asking whether some entertained possibility is or is not actual. Reality testing refers to a more primordial mental function; autism refers to its preclusion.

[3] Petocz’s (1999) thinking on symbol formation tends in this direction. Klein’s (1930) The importance of symbol-formation in the development of the ego might lead one to a different yet similarly limited view – of symbol-formation arising solely through an iterative process of hate displacement. At first hating the unavailable or pain-providing breast, the child displaces this hatred onto a substitute (to save himself from the breast’s feared retaliations), and this process continues as the imagined retaliations of each substitute become feared in turn. It is hard to see how symbolisation in Klein’s sense could have anything much to do with the establishing of healthy reality contact; it seems rather to be solely a motor for the formation of paranoid worlds. 

[4] Here symbols are somewhat akin to Winnicott’s transitional objects, but since the important theory of transitional space has many complex and debatable theoretical tenets it is not elucidatory to appeal to it here.

[5] Segal distinguishes symbolic equation from symbolism in terms of what the symboliser feels to be the case. [find ref] The subject making a symbolic equation between playing the violin and masturbating feels that the two are identical; the subject symbolising the latter with the former does not. This is not wrong, but it is unclear, since the notion of what someone ‘feels to be the case’ is itself unclear. In this chapter I have suggested that it is the mode of thought (and not a feeling per se) in which symbolism obtains that makes for its delusionality or otherwise. [or I could say: we can understand what this feeling is in terms of the distinction between autism and reality contact. We can explicate Segal’s distinction. Nb the distinction between paranoid-schizoid and depressive positions, in which symbolic equations and symbolism proper obtain, is also significant here. The subject in the depressive position is able to move between different relations to the same symbolisation. Or I could put it differently or better: that we sometimes have to do with symbolisation and sometimes to do with symbolism. We have the latter, and its more progressive accommodative possibilities, when the symbol helps him make comprehending contact with his feelings for his beloved. The former obtains when we have substitutive satisfaction – and this is what drives Segal’s ‘feeling of reality’. I need to figure out how to clearly distinguish: symbolism/symbolisation - autism/reality – paranoid-schiz/depressive – etc. how far do these distinctions map onto each other, and how much cut across each other?

[6] Cf Lars and the Real Girl  - a film in which a sex doll forms a transitional object for a man struggling to relate to women in an adult way – and in which the community supports him in this until he is able to relinquish it.