Sunday, September 05, 2010

Are People Responsible for Acting on Delusions? by guest blogger Lisa Bortolotti

Consider this case. Bill suffers from auditory hallucinations in which someone is constantly insulting him. He comes to believe that his neighbour is persecuting him in this way. Exasperated, Bill breaks into the neighbour’s flat and assaults him. Is Bill responsible for his action? Matthew Broome, Matteo Mameli and I have discussed a similar case in a recent paper. On the one hand, even if it had been true that the neighbour was insulting Bill, the violence of Bill’s reaction couldn’t be justified, and thus it is not obvious that the psychotic symptoms are to blame for the assault. On the other hand, psychotic symptoms such as hallucinations and delusions don’t come in isolation, and it is possible that if Bill hadn’t suffered from a psychiatric illness, then he wouldn’t have acted as he did.

In the philosophy of David Velleman, autonomy and responsibility are linked to self narratives. We tell stories about ourselves that help us recollect memories about past experiences and that give a sense of direction to our lives. Velleman’s view is that these narratives can also produce changes in behaviour. Suppose that I have an image of myself as an active person but recently I neglect my daily walk and spend the time in front of the TV. So I tell myself: “I have to get out more or I’ll become a couch potato”. I want my behaviour to match my positive self-image so I can become the person I want to be. Our narratives don’t just describe our past but can also issue intimations and shape the future.

According to Phil Gerrans, who has applied the notion of self narratives to the study of delusions, when experiences are accompanied by salience, they become integrated in a self narrative as dominant events. People with delusions tend to ascribe excessive significance to some of these experiences and, as a result, thoughts and behaviours acquire pathological characteristics (e.g. as when Bill is exasperated by the idea of someone insulting him). Gerrans’ account vindicates the apparent success of medication and cognitive behavioural therapy (CBT) in the treatment of delusions. Dopamine antagonists stop the generation of inappropriate salience, and by taking such medication, people become less preoccupied with their abnormal experiences and are more open to external challenges to their pathological beliefs (“How can I hear my neighbour’s voice so clearly through thick walls?”) In CBT people are encouraged to refocus attention on a different set of experiences from those contributing to the delusional belief, and to stop weaving the delusional experiences in their self narratives by constructing scenarios in which such experiences make sense even if the delusional belief were false (“Maybe the voice I’ve heard was not my neighbour’s.”)

As Gerrans explains, self narratives are constructed unreliably in the light of abnormal experiences and delusional beliefs. If we take seriously the idea that self narratives may play an important role in the governance of behaviour, and accept that narratives constructed by people with delusions are unreliable, then it’s not surprising that people with delusions are not very successful at governing themselves.

8 comments:

Badda Being said...

Are people responsible for acting on facts?

Badda Being said...

Or perhaps I should ask: Are people responsible for constructing their narratives? And: Are distinctions between facts and delusions narratively produced?

Lisa Bortolotti said...
This comment has been removed by the author.
Lisa Bortolotti said...

Hi Badda Being - yours are tough questions and I may not have the answers you were looking for. Briefly:

(1) If recent accounts of the 'narrative module' proposed by psychologists and neuroscientists are right, we construct narratives no-matter-what, but mostly these narratives are implicit and they come to our conscious attention only when something unusual happens or we deliberately reflect on our past or on our selves. In the post, I was suggesting that narratives are a tool for achieving autonomous agency.

(2) In my view, delusions are beliefs. So they are distinct from facts. The narrative plays no special role in the distinction between facts and beliefs about facts.

Hope this helps a little!

Badda Being said...

I'm stuck on the meaning of an unreliably constructed narrative. It seems as if autonomy is adjudicated according to an implicit meta-narrative by which self-narratives are counted or discounted as proper facilitators of autonomy, that is, as reliable constructions. But what assurances do you have that such a meta-narrative is not itself an unreliable construction, that is, delusional

Badda Being said...

Let me put this differently. The reliability of a self-narrative construction upon which autonomy is based seems to be adjudicated according to an implicit meta-narrative, but we have no assurances that such a meta-narrative is itself reliably constructed, which is to say not delusional. So the question of autonomy seems to be reducible to the question of whether a person is -- paradoxically -- enslaved within the narrative status quo concerning self-narrative constructions

Lisa Bortolotti said...

I see. I don't think there needs to be any meta-narrative. Narratives are assessed on the basis of (1) internal coherence and (2) empirical adequacy, or in psychological jargon, correspondence. Now you may ask, correspondence to what? To reality.

Now, facts may be interpreted differently, but there is an intersubjective space, a space in which people and environment interact causally, and narratives are either accurate in representing it or they are not. You don't need to be delusional to construct your narrative unreliably: maybe it's unfailing optimism or self-deception leading to see things in an overly positive light. 'My husband still loves me' or 'I failed the exam because I was distracted', etc.

In any case, I'm not the greatest expert on narratives. I recommend the paper by Gerrans I mentioned in the post, which you can find here: Mad scientists or unreliable narrators? Dopamine dysregulation and delusion, in M. Broome and L. Bortolotti (eds), Psychiatry as Cognitive Neuroscience: Philosophical Perspectives, Oxford University Press, 2009.

Badda Being said...

A meta-narrative can be thought of as an averaging out of narratives which populate the intersubjective space, according to which internal coherence and empirical adequacy undergo diachronic and synchronic mutations. So the question of autonomy still seems to reduce to the question of adequation to an ever-shifting status quo