On the Architecture of Psychosis:
Thoughts and Delusions of Thought Insertion
A thesis submitted to the University of Manchester for the degree of Doctor of Philosophy in the Faculty of Humanities
2015
Pablo López Silva
School of Social Sciences
Contents
ABSTRACT 5
DECLARATION 6
COPYRIGHT STATEMENT 7
ACKNOWLEDGMENTS 8
INTRODUCTION: MAPPING THE TERRAIN 10 1. WHAT ARE DELUSIONS? 11 1.1. THE TYPOLOGY PROBLEM 12 1.2. THE AETIOLOGICAL PROBLEM 17 1.2.1. BOTTOM-UP VS. TOP-DOWN APPROACHES 17 1.2.2. ENDORSEMENT VS. EXPLANATIONIST APPROACHES 19 2. ON THE HETEROGENEITY OF DELUSIONS: KEY DISTINCTIONS 20 2.1. FUNCTIONAL-ORGANIC / MOTIVATION-DEFICIT DELUSIONS 21 2.2. MONOTHEMATIC VS. POLYTHEMATIC DELUSIONS 22 2.3. CIRCUMSCRIBED VS. ELABORATED DELUSIONS 22 2.4. PRIMARY VS. SECONDARY DELUSIONS 23 2.5. BIZARRE VS. MUNDANE DELUSIONS 23 3. WHAT IS THOUGHT INSERTION? 24 3.1. THOUGHT INSERTION: MAIN SUBJECTIVE FEATURES 25 3.2. DISAGREEMENTS SURROUNDING THE SUBJECTIVE FEATURES OF THOUGHT INSERTION 29 3.3. THE DIAGNOSTIC ROLE OF THOUGHT INSERTION IN PSYCHIATRY 32 4. THE PHILOSOPHICAL RELEVANCE OF THOUGHT INSERTION: MAKING SENSE OF THE COLLECTION 35 5. REFERENCES 39
CONSCIOUS THOUGHTS AND ATTRIBUTIONS OF MENTAL AGENCY: 45
AN AFFORDANCE MODEL 45 1. FROM SELF-ATTRIBUTIONS OF BODILY MOVEMENTS TO SELF-ATTRIBUTIONS OF THOUGHTS 46 2. EXPERIENCING AND SELF-ATTRIBUTING THOUGHTS: A LAND OF DISAGREEMENTS 49 2.1. THE PHENOMENAL CHARACTER OF THOUGHTS: A LIBERAL STANCE 49 2.2. MODALITIES OF MENTAL-SELF ATTRIBUTION: SUBJECTIVITY, OWNERSHIP, AND AGENCY 50 2.3. THE PHENOMENOLOGICAL PASSIVITY OF THOUGHTS 54 3. EXPLAINING SELF-ATTRIBUTIONS OF MENTAL AGENCY 60 3.1. THE TOP-DOWN FORMULATION 60 3.2. THE BOTTOM-UP FORMULATION 63 4. ATTRIBUTIONS OF MENTAL AGENCY, PSYCHOSIS, AND THINKING AS A MOTOR PROCESS 66 5. AFFORDING MENTAL AGENCY: A PROPOSAL 69 6. IMPLICATIONS OF THE AFFORDANCE MODEL OF MENTAL AGENCY: EXPLAINING EXTERNAL ATTRIBUTION 73 7. CONCLUDING REMARKS 76 REFERENCES 77
2 THOUGHT INSERTION AS HYBRID DELUSIONAL BELIEFS 82 1. INTRODUCTION 83 2. UNDERSTANDING MADNESS: DOXASTICISM ABOUT DELUSIONS 85 3. BOTTOM-UP EXPERIENTIAL LOADING AND THE CONSCIOUS EXPERIENCE OF THOUGHT INSERTION 88 3.1. REPORTS ON THOUGHT INSERTION 89 3.2. TWO DOXASTIC ROUTES TO DELUSIONAL BELIEFS OF THOUGHT INSERTION 90 3.2.1 THE EXPLANATIONIST ALTERNATIVE 91 3.2.2. THE ENDORSEMENT ALTERNATIVE 92 4. ENDORSEMENT OR EXPLANATION? 95 4.1. THE NON-SENSORY PHENOMENAL NATURE OF THINKING 95 4.2. SUBJECTIVE CERTAINTY 97 4.3. THE AMBIVALENCE PROBLEM: TO BE, OR NOT TO BE? 99 4.4. THE EXPERIENTIAL ENCODING PROBLEM 104 4.4.1. THE INCREDIBILITY OBJECTION 104 4.4.2 THE NON-AGENCY OBJECTION 106 4.5. THE DOXASTIC ENCODING PROBLEM 107 5. TOWARDS A POTENTIAL SOLUTION: THOUGHT INSERTION AS HYBRID DELUSIONAL BELIEFS 110 6. CONCLUDING REMARKS 114 REFERENCES 115
PSYCHOSIS AND THE ROLE OF AFFECTIVE IMPAIRMENTS IN THE AETIOLOGY OF THOUGHT INSERTION 119 1. AFFECTIVE STATES AND TWO STORIES ABOUT THE FORMATION OF DELUSIONS 120 2. THOUGHT INSERTION: MAIN SUBJECTIVE FEATURES 124 3. IMPAIRMENTS IN AFFECTIVITY AND THE FORMATION OF DELUSIONS 125 4. AFFECTIVE ROUTES TO DELUSIONS: THOUGHT INSERTION AS THOUGHT AVERSION 128 5. THE THOUGHT AVERSION HYPOTHESIS UNDER EXAMINATION 131 6. THE PLACE OF EGODYSTONIC STATES IN THE AETIOLOGY OF THOUGHT INSERTION: A PROPOSAL 134 7. EXPLORING A THEORETICAL INTEGRATION 141 8. CONCLUDING REMARKS 142 REFERENCES 144
PSYCHOSIS AND THE SUBJECTIVITY OF PHENOMENAL CONSCIOUSNESS 148 1. INTRODUCTION 149 2. MINENESS AND SELF-CONSCIOUSNESS: MAPPING THE DEBATE 149 2. THE SELF-PRESENTATIONAL VIEW OF CONSCIOUSNESS 152 2.1. FROM CONSCIOUSNESS OF EXPERIENCES TO SELF-CONSCIOUSNESS 152 2.2. FROM A SENSE OF MINENESS TO SELF-CONSCIOUSNESS 153 2.2.1. PHENOMENAL CHARACTER 154 2.2.2. DOUBLE STRUCTURE OF CONSCIOUS EXPERIENCES 155 2.2.3. SUBJECTIVE CHARACTER 156 3. THE SPV AND THE CHALLENGE FROM PSYCHOPATHOLOGY 157 3.1. THOUGHT INSERTION AS A DISRUPTION IN THE SENSE OF MENTAL AGENCY 159 3.2. STREAM OF CONSCIOUSNESS AND SENSE OF MINENESS VIA LOCATION 163 4. CONCLUDING REMARKS 167 REFERENCES 169
MAKING SENSE OF THE ADAPTIVE ROLE OF PSYCHOTIC DELUSIONS 173
3 1. DELUSIONS AS MALADAPTIVE MISBELIEFS 174 2. MAPPING THE DEBATE: MODES OF ADAPTIVENESS AND THE TYPES TO DELUSIONS 176 2.1. MODES OF ADAPTIVENESS OF BELIEFS 177 2.1.1. PSYCHOLOGICAL ADAPTIVENESS 177 2.1.1. BIOLOGICAL ADAPTIVENESS 177 2.2. TWO TYPES OF DELUSIONS 178 2.2.1. MOTIVATED DELUSIONS 178 2.2.2. DEFICIT-BASED DELUSIONS 179 2.2.3. MOTIVATED OR DEFICIT-BASED DELUSIONS? 180 3. DOXASTIC DEFICITS AND THE ADAPTIVENESS OF DELUSIONS 182 4. MAKING SENSE OF THE ADAPTIVE ROLE OF DELUSIONS: A PROPOSAL 184 4.1. THE CONTEXT OF DELUSIONS 184 4.1.1. PRE-DELUSIONAL AFFECTIVITY AND THE FORMATION OF DELUSIONAL BELIEFS 185 4.1.2. DELUSIONAL MOODS AND DELUSIONAL BELIEFS 187 4.2. DELUSIONS AS BIOLOGICALLY ADAPTIVE MISBELIEFS 188 5. CONCLUDING REMARKS 195 REFERENCES 197
CONCLUDING REMARKS 202
4 Abstract
The University of Manchester Pablo Andrés López Silva Doctor of Philosophy On the Architecture of Psychosis: Thoughts and Delusions of Thought Insertion
In its many manifestations, psychosis leads to a number of clinical and philosophical debates. Despite their practical and conceptual importance, a number of these debates remain unresolved. Appealing to the connection between phenomenological descriptions, empirical evidence, and philosophical analysis, this dissertation is devoted to the careful examination of five of the main debates surrounding the occurrence of delusions of thought insertion, one of the most complex and severe symptoms of psychotic disorders. Roughly speaking, patients suffering from thought insertion report that external agents of different nature have placed certain thoughts into the patients’ minds.
The introduction to this compilation clarifies the main distinctions underlying the general discussions about delusions and the specific debates surrounding thought insertion. The introduction is followed by a collection of five papers. The first paper tries to explain the way in which subjects self-attribute their own conscious thoughts in terms of agency. The second paper, assuming that delusions are a type of belief, engages with the discussion about the role that experiential abnormalities have in the process of formation of the delusional belief of thought insertion. The third paper examines the role that affective impairments might have in the process of production of thought insertion, an issue that is often overlooked by current dominant approaches to thought insertion. Taken altogether, the first three papers of this collection offer a novel understanding of the aetiology and architecture of thought insertion.
The fourth paper examines a much larger discussion that overlaps with the debate about the subjective features of thought insertion. It is argued that cases of thought insertion – in conjunction with other psychotic phenomena – undermine the current self-presenting theory of consciousness, a theory meant to explain the most fundamental subjective character of conscious experiences. Finally, the fifth paper of the compilation engages with a more general discussion about the nature and role that delusions might play in a subject’s life. It is argued against the dominant view that there are good reasons to characterize a certain type of monothematic delusions (including some cases of thought insertion) as biologically adaptive.
5 Declaration
No portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning.
6 Copyright Statement i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents, designs, trade marks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. iv. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=487), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see http://www.manchester.ac.uk/library/aboutus/regulations) and in The University’s policy on Presentation of Theses.
7 Acknowledgments
There are certain things in life that cannot be done without the support of others; this dissertation is a clear example of that. Although it has been the most intense period of my life, the indelible support of many people made of this journey a pleasant and unforgettable experience.
I thank God for not giving up on me, and for giving me the strength to keep going during all these years. I shall also express my deepest gratitude to the persons to whom I own everything, my parents. There are no words to express how much I love and admire you. This dissertation is not only the result of my individual work, but also an extension of everything they have done for me over all these years; it is also the product of all their sacrifices. To my girls, Carolina and Marilú; you are not only my sisters, you are my main confidants, over all these years your words gave me exactly what I have needed during my most difficult moments. I thank my brother in law, and of course, my nephew who, through his smile, was capable of bringing me to his side regardless of the distance.
My most sincere appreciation also goes to my supervisors. Thanks Joel for your overwhelming support and commitment over all these years. Thanks for seeing in my initial ideas something not even I could see. Thanks Tim for your dedication and for making my ideas better. Thank you both for being always there when I needed it and for teaching me how analytic philosophy is properly done. I extend my gratitude to all those people who provided penetrating comments in different stages of my research, Prof Dr Thomas Fuchs, Dr Roberta Payne, Prof Thomas Uebel, Dr Tom McClelland, Prof Max Coltheart, among many others. I also thanks the financial support provided by the BECAS-CHILE programme of the National Commission for Scientific and Technological Research of the Chilean Government (CONICYT).
Finally, I thank my friends. To those in Chile who remained by my side regardless of the distance. Cristian, Mauricio and many others, thanks for always being there. To those that Manchester brought to me. To Rob and Leo, for friendship and support greater than I could have wished for, and crazy times together. Thanks for being responsible for some of my best memories during my time in Manchester. To Matias and the González-Radrigán family, for all your love, dedication, and support. Certainly, your friendship and brotherhood is something that cannot be forgotten.
8
To my Parents, Nelly and Luis
9 Introduction: Mapping the Terrain
Summary
Madness has been among us since our very beginnings. From the victims of the demon Grahi in ancient Hindu culture to the Biblical story about the madness of Nebuchadnezzar, king of Babylon, insanity has occupied an important place in human history1. The study of madness touches on some of the most fundamental aspects of our existence as human beings. Since modern times, madness has been regarded as a matter of perceiving things that do not exist and believing things that are not the case and although its definition has been refined many times over time, this view remains dominant until today. Certainly, madness cannot and should not be reduced to a mere bundle of hallucinations and delusions; but these phenomena serve as the main starting point for studying madness. Hence, they have central clinical and conceptual importance. The papers contained in this collection constitute a portion of a much larger doctoral research project devoted to the exploration of some of the most relevant issues surrounding the occurrence of a specific type of delusional phenomena, namely, psychotic delusions of thought insertion. Persons who suffer from this delusion report being first-personally aware of a thought that has been placed in their mind by an external agent of different kind (Schneider, 1959; Mellor, 1970; Mullins & Spence, 2003). The main purpose of this introduction is to set up a comprehensive framework for the development of the different issues that will be treated in each paper of this dissertation. Thus, this introduction will be dedicated to the exploration and clarification of some of the most relevant conceptual and technical distinctions that underlie the general understanding of delusions, and the specific debate about the occurrence of thought insertion in current literature.
In section 1, I briefly engage with two general debates about delusions: the debate about what type of mental state delusions are (the typology problem), and the discussion about the origin of delusional phenomena (the aetiology problem). In section 2, I clarify some of the most relevant distinctions regarding the origin, scope, and themes of delusions. In Section 3, I turn to the discussion of specific issues underlying the occurrence of delusions of thought insertion. Section 3.1 provides a clarificatory analysis of the main phenomenological features that any plausible theory of thought insertion should be able to explain. In section 3.2 I examine the diagnostic
1 For a brief and comprehensive description of the evidence of mental insanity in different periods of history see: Porter (2003, Chapter 2 and 3).
10 importance of thought insertion in psychiatry. Finally, section 3.3 analyses the philosophical relevance of the study of thought insertion serving as a summary and presentation of the ideas that tie together the different papers that comprise this dissertation.
Isn’t insanity the mystery of mysteries?
Roy Porter
1. What are Delusions?
Delusional cases have been documented since the 1600s, and, given their strange nature, they have always challenged the notions that philosophers and clinicians have about the normal functioning of our mind. One of the first questions demanding a clear answer in this context is the one about what type of mental states delusions are. Delusions have been usually regarded as the hallmark of psychosis2. As Jaspers (1963) claims: ‘since time immemorial, delusion has been taken as the basic characteristic of madness. To be mad was to be deluded’ (p. 93). Nowadays, delusions are taken as a major symptom of a number of psychiatric conditions such as schizophrenia, although they can be also observed in neurological medical conditions such as dementia (Coltheart, Langdon & McKay, 2011). Delusional phenomena are heterogeneous in scope, theme, aetiology, and phenomenological features, and their understanding requires a great deal of cooperation between different disciplines such as psychopathology, clinical psychology, neuropsychiatry, philosophy, just to name a few (Fulford et al. 2013; López-Silva, 2014).
Some delusions are bizarre in nature. The belief that one is dead and that one’s internal organs are rotten is clearly a bizarre type of belief (Cotard delusion). However, not all delusions are bizarre. In fact, some of them might be even true in different circumstances. Take the case of the belief that my mother is a serial killer, or that my nephew is a mathematical genius. Although they are not the case – not that I know of at least – they might be true. A key issue here is that although delusions are reported with variable degrees of conviction, what unifies them all is that they are not given up easily in face of plausible counterevidence, as non-delusional people would do (Bortolotti, 2010; 2012). Once we pay closer attention to them, delusions become a source of a number of empirical and conceptual puzzles. In the remainder of this section, I shall clarify some of the most relevant puzzles as a way of setting up the general framework in which the ideas defended in each paper of this collection take place.
2 Psychosis translates from the Greek into ‘illness of the soul or mind’.
11 1.1. The Typology Problem
A key debate surrounding the occurrence of delusions is the one concerning the type of mental state that in which delusional reports are grounded. When John says he is watching a movie, we conclude without further discussion that his statement is grounded in a perceptual experience. When Sophie says she was thinking about what would it be like to be a caveman, we uncontroversially conclude that she was imagining that something was the case. However, what can we say in cases where a subject asserts that she is dead (Cotard delusion; Berrios & Luque, 1995), her bodily movements are under control of aliens (Delusions of alien control; Firth, 1992), or when she says she is in both Paris and Boston at the same time (Weinstein & Kahn, 1955)? All these cases are usually regarded as delusions, but what types of mental state are these patients reporting? Are delusional reports grounded in actual perceptual states? Does this make them perceptual states? Are they just the product of unmonitored imaginative activity that ends up deceiving the subject? Let’s call this the typology problem.
One of the most influential approaches to the typology problem has been the so-called doxastic approach to delusions. This view takes its name from ‘doxa’, Greek word for belief or opinion and holds that delusions are a type of belief (Bayne & Pacherie, 2005; Bortolotti, 2010; 2012; Bayne & Hattiangadi, 2013). A number of researchers in current neuropsychiatry have endorsed this view and claim that in order to understand delusions, philosophers and practitioners should have a close look at the different perceptual and cognitive mechanisms involved in the production of beliefs (Maher, 1974; Coltheart, 2002; 2009). Thus, the idea is that by understanding how these mechanisms break down under certain circumstances, we might be able to decipher the psychogenesis of delusions (Coltheart, 2005; 2015)3. The doxastic view seems to have a number of advantages. Let’s here explore some of them.
First, it seems to be able to make sense of some of the most basic issues related to the diagnosis of delusions. Usually, delusions are reported with a considerable degree of subjective certainty. This issue can be plausibly explained if we conclude that delusions are beliefs because high degrees of subjective certainty seem to be characteristic of beliefs (Langdon & Bayne, 2010). However, it is important to note that the degree of subjective certainty with which
3 The fundamental rationale behind the doxastic approach has its roots in Locke’s notion of madness. In his Essay on Human Understanding, Locke (1961) suggests that madness was due to faulty associations in the process whereby sense data (experiential inputs) were transformed into ‘ideas’ (beliefs) (for a contemporary version of this idea, see Maher (1974). Porter (2003) claims that Locke’s notion of madness as the result of different impairments in the process of formation of ideas became central to the new thinking about mental conditions in Britain and France around 1700 (p. 127). In fact, the term ‘delusion’ was first used as referring to mental problems around the same date.
12 delusions are reported varies considerably from subject to subject (Parnas, 2003)4. In addition to this last point, it has been noted that delusions are usually reported as beliefs by patients (Bortolotti & Miyazono, 2014). Generally, when asked whether they really believe what they report in psychotherapy, delusional patients claim that they really do so (Bisiah & Gemianini, 1991). For example, when asked if he really believed what he was reporting, one of my patients exclaimed ‘what do you mean? Of course! I’m not inventing it!’5. This type of reply and the high degree of subjective certainty commonly associated with delusional reports offer some prima facie reasons to endorse a doxastic view of delusions.
Second, the doxastic view offers a conceptually and phenomenologically appealing way to distinguish delusions from other types of psychopathological mental states. While delusions reflect disturbances in the process of formation of beliefs, hallucinations, for instance, might reflect disturbances related to perceptual processes (Langdon & Bayne, 2010). Indeed, this ability is always desirable for it allows clinicians to develop a more specific diagnostic, which in turn might guide better-defined and more specific treatments in psychotherapeutic contexts.
Third, the doxastic approach provides a robust conceptual framework to guide empirical research on delusions (Davies, 2000; Coltheart, 2002). Once we accept delusions are beliefs, psychiatrists and philosophers would only need to focus on the way human beings come to form beliefs and understand the different alterations of these mechanisms that give raise to delusions (Coltheart, 2015). Naturally, here the challenge is to explore and comprehend such mechanisms in the adequate ways.
Despite these advantages, several authors have argued that the doxastic approach fails to make sense of delusions in a plausible way. The anti-doxastic argumentation can be divided into two main aspects. Whilst the negative aspect refers to the reasons offered by the anti-doxastic to believe that delusions are not beliefs, the positive aspect refers to the alternative answers that advocates of anti-doxasticism offer to the typology problem. Bayne & Pacherie (2005), Bortolotti (2012), Bayne (2010), among many others, have developed a number of plausible counterarguments against different anti-doxastic positions, so the doxastic approach remains the strongest position in the typology debate.
4 I engage with this issue further in paper 2 of this compilation. 5 R was a schizophrenic patient who, among other symptoms, had the delusional belief of being able to have conversations with Elvis Presley every morning. He said that Elvis came every morning to the psychiatric hospital to have a chat with him. Along with this belief, the patient also claimed that he was in a relationship with Maura Rivera, dancer from a popular Chilean TV show at that time.
13 Roughly speaking, these are the main negative arguments supporting anti-doxastic positions about delusions:
(a) Responsiveness: M is a belief of the subject if and only if M is responsive to evidence. (b) Integration: M is a belief of the subject if and only if M is integrated with other beliefs of the subject. (c) Action-guidance: M is a belief of the subject if and only if M guide action.
Advocates of anti-doxasticism claim that delusions fail to perform the roles of paradigmatic beliefs: they are not responsive to evidence, they are not integrated with other beliefs of the subject, and they do not guide actions (see for example Currie & Jureidini, 2001; cf. Bayne & Pacherie, 2005; cf. Bortolotti & Miyazono, 2014). They therefore conclude that one should not characterized delusions as beliefs. As a consequence of this drastic conclusion, a number of positive proposals are identified. It has been suggested that delusions might be better characterized as cognitive imaginings, i.e. imaginative states that are misidentified by the subjects as beliefs (Currie, 2000; Currie & Jureidini, 2001)6. Hohwy and colleagues argue that delusions should be understood as the result of perceptual inferences (Hohwy & Rosenberg, 2005; Hohwy & Rajan, 2012). Egan (2009) claims that delusions are bimaginations, i.e. states with some belief-like and imagination-like features, and Schwitzbegel (2012) finally concludes that we should think of delusions as neither beliefs nor non-beliefs, but rather, as in-between beliefs.
In this compilation, I take a doxastic stand towards delusional phenomena. I believe that the negative arguments presented by the anti-doxastic are not sufficient to reject the doxastic approach and all its advantages. The mere fact that delusions fail to perform some of the roles typically associated to paradigmatic beliefs is not sufficient reason to say that they are not beliefs at all (Reimer, 2010). One might say that they are not paradigmatic beliefs, or as Mckay and Dennett (2009) suggest, they are misbeliefs, beliefs that are not correct in all particulars (p. 493). Certainly, the fact that penguins cannot fly does not entail that penguins are not birds at all, rather, they are just birds that cannot fly. If we define a belief simply as a mental state of a subject that implements or embodies that subject’s endorsement of a particular internal or external state of affairs as actual (see McKay & Dennett, 2009, p. 493), delusions can clearly count as a type of belief. Moreover, the following three points suggest that delusions honour (a), (b) and (c) above, after all.
First, there is a very basic point to make about the responsiveness objection: it is just not
6 For a complete assessment of this approach, see Bayne & Pacherie (2005).
14 true that delusions are never responsive to counter evidence. As Schreber (1988) observes in his Memoirs of My Nervous Illness, ‘what objectively are delusions and hallucinations are to him [the patient] unassailable truth and adequate motive for action’ (p. 282, my emphasis). Now, from a more practical point of view, take the case of Cognitive Behavioural Therapy (CBT), perhaps the most popular approach to the treatment of delusions. This approach is premised in the idea that delusions are a type of belief (Alford & Beck, 1994). One of the main technics of CBT consists in questioning the patient’s delusional belief in light of counterevidence (Dickerson, 2000). CBT has been proven highly effective in the treatment of some delusions and such efficacy can be accounted by the fact that delusions are sometimes responsive to counterevidence (Garety et al. 1997)7. In this context, the truth is that delusions are sometimes responsive to evidence while other times they are not.
The second point regarding the responsiveness objection is that the argument is based on the idea that paradigmatic beliefs are necessarily rational in virtue of their responsiveness to evidence. However, this objection seems to be way too demanding for it has been shown that, sometimes, not even ordinary beliefs are entirely responsive to counterevidence (Nisbett & Ross, 1980; Bortolotti, 2010). Clear examples of ordinary beliefs lacking the degree of responsiveness to evidence supposedly characteristic of paradigmatic beliefs are racist and sexist beliefs. A male sexist subject might have the belief that being a woman is enough for that subject to be considered as inferior in many ways. Sexist beliefs are the result of a number of biases, and they lack the degree of responsiveness to evidence that paradigmatic beliefs exhibit; however, they are not denied the belief status. The problem with this objection is that some of our ordinary beliefs are irrational in the same way delusions can be therefore, the objection establishes a requirement that not even some ordinary (non-delusional) beliefs meet. Nonetheless, it is important to note that the main difference between delusional and non-responsive ordinary beliefs seems to be given by the degree of responsiveness. Irrational ordinary beliefs seem to be more responsive to evidence than delusional beliefs and the challenge for the advocate of the doxastic approach is to account for this difference8.
Second, in developing the integration objection, Currie and Jureidini (2001) conclude that delusions ‘[fail], sometimes spectacularly, to be integrated with what the subject really does
7 In fact, a great portion of the therapeutic work in the treatment of delusions can be explained by the fact that delusions are sometimes responsive to counterevidence. 8 It is interesting to note that many delusional cases seem to be an exacerbation of the content of some ordinary (but not originally delusional) subjective themes. This seems to be case of jealousy and morbid jealousy, functional obsessive thought of contamination and parasitosis, just to name a few. Prima facie, these cases offer another reason to believe in doxasticism about delusions.
15 believe’ (p. 161). First, it is important to note that it is not clear how Currie and Jureidini are in position to know what the patient really believe. If we take delusional reports at face value and consider the way in which patients report their delusional episodes, one might be able to say without much discussion that they do believe that aliens are controlling their bodily movements, that they are dead, that machines insert thought into their mind, and so on. The problem here is that delusional beliefs seem not to be integrated with some other beliefs of the subject. However, in this context we can ask two simple questions: (i) do delusions really fail to be integrated with other beliefs of the subject? The answer seems to be ‘not always’. In many cases delusions are integrated well with other beliefs of the subject (Bortolotti, 2010). Prima facie, the patient that planned to remove one of his two heads with an axe was able to integrate his ‘perceptual delusional bicephaly’ with the belief with the content (see Ames, 1984). (ii) Are paradigmatic beliefs always integrated between each other? The answer seems to be, again, ‘not always’. The main problem with this objection is that the failure of delusions to be integrated with some other beliefs of the subject is exaggerated and therefore, it imposes a requirement that not even ordinary beliefs meet. However, as Bortolotti (2010) claims, it is necessary to note that delusions are evidently less integrated than ordinary beliefs so they show the mark of irrationality (bad integration) to a higher degree than non-delusional beliefs. This is a phenomenon that the advocate of the doxastic view should be able to explain.
Finally, the action-guidance objection seems to have prima facie counter evidence for it looks like a great number of deluded patients do act on their delusional beliefs (de Pauw & Szulecha, 1988). Blount (1986) reports a case of a patient suffering from Capgras delusion that decapitated his stepfather trying to find the batteries in his head. Certainty, the action of decapitation was guided by the belief that the patient’s stepfather was some kind of machine. Similarly, Young and Leafhead (1996) showed that all Cotard patients showed some form of delusion-related behaviour. In fact, after planning to remove his second head with an axe, the aforementioned patient with perceptual delusional bicephaly decided to remove it with a gun leading this to a number of injuries (see Ames, 1984). A number of patients with delusions of superhuman strength have been reported injured after acting on their delusions (Petersen & Stillman, 1978). These cases show that, sometimes, delusions do guide actions in deluded patients.
A refined version of this objection might propose that delusions fail to produce the right kind of action and emotional response that patients are expected to produced if delusions were beliefs. For instance, it is claimed that some patients suffering from the Capgras Delusion, who
16 claim to have beliefs with the content
Second, having a certain belief is different from the behaviour derived from it. It has been shown that schizophrenic patients tend to have problems with introspection and general problems with identifying their own mental states (Taylor et al, 1997). Sass and Parnas (2003) conclude that schizophrenic patients usually show a condition called ‘hyperreflexivity’, i.e. an exacerbated explicit awareness of otherwise tacit elements that usually remains in the background of consciousness. Arguably, one might say that hyperreflexivity arises in the context of an informational surplus in consciousness that does not allow the patients to behave in the way that it is expected when having a certain clear and well-identified belief.
Third, do we always behave consistently with our beliefs? Is it ‘expected behaviour’ a good parameter to distinguish between those states that are beliefs and those that are not? It seems that we do not always act consistently with the beliefs we hold. One can have the belief that there is a helper God that looks after his sons while acting as though there is no God. The truth is that most of the anti-doxastic argumentation seems to rely on an idealization of normal belief states imposing constraints on delusional phenomena that not even ordinary beliefs would meet. Therefore, there seems not to exist sufficiently compelling reasons to reject the doxastic approach.
1.2. The Aetiological Problem
1.2.1. Bottom-Up vs. Top-Down Approaches
A second debate associated with the occurrence of delusions is the one concerning their origin. Let’s called this the aetiological problem. Once we accept that delusions are fundamentally beliefs, we need to explore the causal direction between beliefs and experience in the context of formation of delusions. Here, a popular distinction between bottom-up and top- down approaches has been introduced to distinguish between two different ways of thinking
17 about the causal direction between beliefs and experience (Bayne & Pacherie, 2004a)9. While advocates of bottom-up views claim that ‘the proximal cause of the delusional belief is a certain highly unusual experience’ (Bayne & Pacherie 2004a, p. 2), those defending top-down approaches suggest that delusions are ‘a matter of top-down disturbance in some fundamental beliefs of the subject, which may consequently affect experiences and actions’ (Campbell 2001, p. 89). As we can see, in bottom-up approaches the causal relation goes from experience to belief (Maher, 1974; Maher, 2003; Coltheart, 2005; McKay, Langdon & Coltheart, 2009), whilst in top- down approaches it goes from belief to experience (Campbell, 2001)10. For instance, if as subject S is aware of a thought T accompanied by number of abnormal features, S might form the doxastic hypothesis that T has been created by an external agent and has been inserted into S’s mind. This bottom-up picture of thought insertion might be re-described in a top-down fashion by saying that certain beliefs in S about how external agents under certain conditions can insert ideas into S’s mind influences and defines the way S experiences his thoughts leading up to a conscious episode of thought insertion.
When exploring the top-down/bottom-up debate, explanatory theories should be flexible. Both bottom-up and top-down approaches face different challenges. On the one hand, top-down advocates struggle to account for the origin of the bizarre belief and how such a belief affects perceptual experiences so effectively. On the other hand, bottom-up advocates need to explain how subjects tend to endorse such a bizarre doxastic hypothesis in light of more plausible alternatives available. In this context, in order to set up a more integrative framework for the exploration of the psychogenesis of delusions, two suggestions can be made:
(a) The weaker suggestion is to recognize that although the top-down/bottom-up distinction is clear, useful, and didactic, it should not be understood as exclusive. It might be the case that some delusions are better explained in top-down terms while others in bottom-up terms. Top-down models might work better to explain certain delusional cases while bottom-up models might explain others. For example, plausible bottom-up accounts of Capgras delusion have been defended by appealing to impairments in the affective component of face recognition (Ellis & Young, 1990; Stone & Young, 1997). In contrast, it seems that delusional parasitosis can be better explained by top-down accounts for it is doubtful that the experience of being infected by parasites could have this content without top-down content loading. This weaker suggestion is
9 Sometimes, this distinction is also referred in terms of empiricism (bottom-up) and rationalism (top-down) about delusions (Bayne & Pacherie, 2004b). 10 This type of formulation has been also applied to cases of Capgras Delusion (Campbell 2001; Eilan 2000) and delusions of passivity (Sass 1994; Stephens & Graham 2000).
18 basically that, given their heterogeneity, it is not implausible to think that we need to rely on the conceptual resources of both empiricist and rationalist models in order to explain different types of delusions. The underlying idea here is that delusions involve significant differences in their phenomenological, neuropsychological, and cognitive underpinnings and such differences might suggest that a single model would not have all the necessary resources to explain the whole range of delusional phenomena.
(b) The stronger claim is that the explanation of a single type of delusion should involve both bottom-up and top-down elements (Hohwy & Rosenberg, 2005). Here, in explaining the Truman Show delusions, for example, i.e. the belief that the subject is the star of a reality show from which he cannot escape, researchers should think of it as the result of the interaction between first-order novel experiential inputs and prior beliefs of the subject and this would be the case for the comprehension of all delusions. This option seems attractive when looking at the complexity of the delusions reported by patients, and when trying to make sense of the relationship between these reports and the cultural background of the deluded subjects. In any case, it seems clear that research on delusional phenomena necessarily involves conceptual flexibility when making sense of their aetiology.
1.2.2. Endorsement vs. Explanationist Approaches
The bottom-up side of the debate about the causal direction between beliefs and experience claims that delusions are rooted in experiential abnormalities. Delusional beliefs are a higher order mental state fed by experiential states of different kinds. However, the exact role of these first-order abnormal experiential states in encoding the content of the delusional belief is still the focus of discussion within the doxastic approach to delusions (Sollberger, 2014). Thus, two different alternatives have been formulated. On the one hand, advocates of an endorsement model suggest that the abnormal experience comprises the very content of the delusional belief so patients simply believe or endorse what they have experienced (Bayne & Pacherie, 2004a; 2004b). In other words, patients just trust their experience in the same way we do in normal cases, so on this view the delusional belief is based on an experiential state with the same content.
For example, when a subject reports the delusional belief that she is dead, she does so because she is endorsing an experience with the same content. Contrasting with the endorsement model, the explanationist model suggests that patients adopt delusional beliefs as a way of explaining abnormal experiences that do not have exactly the same content of the doxastic state
19 they underlie (Davies, Coltheart, Langdon & Breen, 2002). Although this alternative implies a basic degree of endorsement of some experiential states, the claim is that these experiential states do not comprise the entire content of the delusional belief, so, in explaining the abnormal experience, patients add certain elements to the experiential states as a way of making sense of them. Therefore, here the delusional belief with the content
Just as in the case of the debate between bottom-up and top-down approaches, when exploring the endorsement-explanationist debate, theorizing should be flexible. While some delusions might be better explained in explanationist terms, others might be in endorsement terms (weaker suggestion). Setting up an integrative framework, Langdon & Bayne (2010) propose that all delusions lie somewhere in a ‘received/reflective’ spectrum. Such distinction should be understood as a continuum where, at one pole, ‘received’ delusions are formed solely via endorsement and at the other pole, ‘reflective’ delusional beliefs would be formed solely via explanationist process. However, Langdon and Bayne (2010) also make a stronger suggestion and they further propose that most delusions are hybrids, namely, they arise from a combination between endorsement and explanationist processes11.
2. On the Heterogeneity of Delusions: Key Distinctions
Delusional phenomena are heterogeneous in many ways. There is aetiological heterogeneity (the origin of delusions can be diverse), and there is also doxastic heterogeneity (they vary both thematically and in scope). People with clinical lycanthropy form the belief that they can transform, or have been already transformed into a wolf (Garlipp et al. 2004). Patients with erotomania believe that another person, often famous, is in love with them and can communicate with them in different ways, for instance, via telepathy (Remington & Jeffries, 1994). While Cotard patients believe they are dead, Capgras patients form the belief that an impostor has replaced a relative, often the spouse. Some delusions arise in the context of brain injury (David & Prince, 2005), while some others emerge in the context of affective problems (Marwaha et al. 2013). In other cases, delusions seem to arise mainly as a way of overcome psychological threatening stimuli (Bell, 2003). Given the heterogeneity of delusional phenomena, a number of distinctions have been proposed to clarify and guide research on the field. In what follows, I examine some of these distinctions.
11 I take this way of approaching the doxastic debate when developing my own account for delusions of thought insertion in paper 2 of this compilation.
20 2.1. Functional-Organic / Motivation-Deficit Delusions
One of the first attempts to group delusional phenomena into different categories was done by appealing to their different psychogenesis (aetiology problem). Delusions used to be divided into functional and organic12. While organic delusions emerged as the result of organic malfunctions, often associated to the right hemisphere of the brain, a delusion was functional when its organic causes were not known (Bentall, 2003)13. These two categories established a sharp separation between the organic and psychological mechanisms involved in the formation of delusions. While organic delusions were associated with malfunctioning portions of the biological architecture of the subject, functional delusions were explained as the result of psychological manoeuvres of the mind (McKay, Langdon & Coltheart, 2009). However, the functional/organic distinction has been regarded as obsolete for it seems to be based on a notorious lack of knowledge of the integration between organic and psychological elements in the process of formation of delusions (Coltheart, McKay & Langdon, 2011). Certainly, these two categories overlap and more importantly, a well-informed research programme on delusions should accept that there must be some kind of deficit underlying all types of delusions, but that in some cases this deficit has not been identified with precision yet.
More recently, the functional-organic distinction has been replaced by a distinction between motivated and deficit-based delusions (see McKay & Dennett, 2009; McKay, Langdon & Coltheart, 2009). Delusions are motivated when their adoption can help the patient to deal with psychologically threatening stimuli and, therefore, they are the result of the normal functioning of human mind (Bortolotti, 2014). Contrasting, the deficit-side of the distinction claims that delusions are necessarily the result of different functional impairments at different stages of the process of belief formation (Maher, 1979; Ellis & Young, 1988; Coltheart, 2002; 2015)14. Just as in the debate about functional and organic delusions, some people think of the motivated/deficit distinction as referring to two alternatives to explain pathological phenomena with necessarily distinct origins. However, at the present stage of empirical research on the formation of delusions, such a view does not seem plausible and most researchers accept that all delusions might involve at least some deficit at different levels of the process of formation of beliefs. So, even if some delusions were motivated, their aetiological route would also imply certain impairments in the machinery in charge of forming beliefs (Bentall et al. 2001). This distinction
12 The organic tradition in psychiatry was pioneered by Emil Kraepelin mostly in his work Compendium of Psychiatry (1883). 13 In both cases delusions were mostly seen as a type of belief, see: Bentall (2003). 14 I explore further different aspects of these categories in Paper 3 and 5 of this compilation.
21 seems to be better interpreted as focused on whether delusions play a palliative function in the patient’s psychological life even if they are the product of different deficits (Mishara & Corlett, 2009). Thus, this distinction offers a more integrative way of thinking about the aetiology of delusions. Certainly, the challenge in this context is to explore, discover, and understand the many deficits that underlie the formation of these phenomena.
2.2. Monothematic vs. Polythematic Delusions
A second way of categorizing delusion is by appealing to differences in the nature of their content. When patients exhibit just a single delusional belief or a small set of delusional beliefs that are all related to a single theme, delusions are monothematic. For example, the delusion that a subject is dead (Cotard delusion) is a monothematic delusion. In this case, the subject holds a specific delusional belief and although some other delusional beliefs might emerge – like the delusional belief of being immortal – they are associated with the main delusional belief (being dead). In contrast, if patients exhibit delusional beliefs about a variety of topics that are unrelated to each other, delusions are polythematic. Capps (2004) comments the case of Josh Nash who believed he was the Emperor of Antarctica, that he was the left foot of God on Earth, and that his real name was Johann von Nassau, among many other delusional beliefs. As we can see, contrasting with monothematic delusions, in this case there is a set of delusional beliefs not necessarily related to each other. While monothematic delusions stick to one theme, polythematic delusions extend to more than one theme. Most current research on the aetiological and philosophical aspects of delusions has been focused on monothematic delusions (Coltheart, McKay & Langdon, 2011).
2.3. Circumscribed vs. Elaborated Delusions
Another distinction has been proposed regarding the scope of delusional beliefs (Coltheart, Langdon & Breen, 2001). Delusions are circumscribed when they do not lead to the formation of other intentional states that might be related to the content of the delusion, nor do they have important effects in the subject’s behaviour. So to speak, delusions are circumscribed when they do not ‘spread’ all over the belief-system of the subject. Delusions are elaborated when the subject reporting draws consequences from the delusion and forms other beliefs that orbit around the main delusions. Elaborated delusions can turn into complex narratives that make sense of the whole delusional situation that the patient is living. In this sense, the circumscribed- elaborated distinction seems to be relevant to specify the degree of integration between the delusional belief and other states of the subject. Davies and Coltheart (2000) claim that while
22 polythematic delusions tend to be elaborated, monothematic delusions tend to be circumscribed. However, it is important to note that the same type of delusion might be circumscribed in some cases and elaborated in some others. For instance, a patient with the belief that her left limb is not hers but belongs to her mother (somatoparaphrenia) but shows no preoccupation for of her original limb and does not look for it seems to have a circumscribed delusion. Now, a patient with the same type of delusion (somatoparaphrenia) might show preoccupation and even develop paranoid thoughts about the situation. In addition, she might engage in behaviours aimed to find her original limb. In this case, the patient would have an elaborated delusion.
2.4. Primary vs. Secondary Delusions
A fourth distinction in this context is the one concerning whether delusional beliefs can be reported on the basis of some reasons, and defended with arguments, or if they appear just ‘out of nowhere’. From this point of view, delusions can be primary or secondary. According to Jaspers (1963), primary delusions – also called true delusions – are distinguished by a transformation of meaning, so that the world or aspects in it are interpreted in a completely different way by the patient (Owen et al. 2004). To non-deluded patients, this interpretation of the world is 'un-understandable' (Fuchs, 2005). On the other hand, Secondary delusions, also called delusion-like ideas, are considered to be understandable on the basis of the subject’s life history, personality, mood state or presence of other psychopathology. For example, a person that becomes depressed might tend to produce low self-esteem related ideas, which, in turn, might make her believe she is responsible for some terrible actions that she did not commit. Jones (2004) has claimed that this distinction is problematic because it is not clear whether secondary delusions might be delusions at all.
2.5. Bizarre vs. Mundane Delusions
There are two main systems of classification of mental disorders, namely, the International Statistical Classification of Diseases and Related Health Problems, (ICD; WHO, 1992), and the Diagnostic and Statistical Manual of Mental Disorder (DSM; APA, 2013). Although it has many problems, the DSM is the system that has remained more popular among clinicians (Coltheart, McKay & Langdon, 2011)15. The DSM-IV-TR makes a distinction between bizarre and mundane delusions. The main criterion for such distinction seems to be the degree of likeliness of the content of the delusion. While the belief that the patient is dead (Cotard’s delusion) would be regarded as bizarre, the belief that the patient’s spouse is having an affair
15 For a philosophically rich discussion about the problematic issues of the DSM system see: Cooper (2004).
23 with her boss will be regarded as mundane. If delusions were understood as belonging to a continuum between normal and false beliefs, bizarre beliefs would be far away from the ‘normal’ side of this continuum; in contrast, mundane delusions would be closer the ‘normal’ side of it as they would be mainly ‘ungrounded’. The main difference is that the content of bizarre delusions is simply not possible, while the content of mundane delusions might be possible. It is just not possible for a dead subject to hold a belief, but it is perfectly possible for a subject’s spouse to have an affair with her boss, putting aside all the moral discussion.
3. What is Thought Insertion?
Having clarified some of the key distinctions that underlie the general understanding of delusional phenomena, let me now turn to some of the general aspects regarding the target phenomenon of this dissertation, namely, delusions of thought insertion. Thought insertion is a monothematic bizarre delusion that has been regarded as one of the most severe and complex symptoms of psychotic disorders (Schneider, 1957; Mellor, 1970). Patients reporting inserted thoughts claim to be first-personally aware of certain thoughts that have been placed into their minds by external agents (Mullins & Spence, 2003). Although the subjective structure of the reports on the phenomenon remains similar, the external agents identified by the patients are considerably heterogeneous in nature. Some of them identify persons (e.g. TV celebrities, relatives; see Frith, 1992), electronic devices (e.g. TVs, radios; see Spence et al. 1997), collective groups (e.g. aliens, the government, secrets societies; see Payne, 2013), and some others refer to surrounding inanimate entities (e.g. houses, trees; see Saks, 2007), among many others.
One of the first practical difficulties of trying to explore thought insertion is the notorious paucity of clinical reports. As Pickard (2010, p. 56) points out, usually: ‘the same patient reports are used again and again, and they do not fully capture the phenomenon’16. In order to deal with this issue, first, I performed a digital search within the most relevant online databases looking for clinical reports on thought insertion17. Second, I spent some time at the University of Heidelberg
16 This problem is not new to research on psychopathology. When trying to compile cases for his Compendium of Psychiatry, Emil Kraepelin found many difficulties to access to clinical reports. In fact, this was one of the main reasons why Kraepelin finally moved from Heidelberg to Munich in 1902 (Bentall, 2003). 17 The literature considered for this compilation was located using the following online databases: Web of Science, Arts & Humanities Citation Index, PsyINFO, Scopus, Elsevier, The Philosopher’s Index, Philpapers, and Jstor. The search was performed in both Spanish and English language. This constitutes an advantage compared to existing reviews on thought insertion that only considered English-language literature. The keywords used were: (English) delusion, thought insertion, schizophrenia, account (approach) for (to) thought insertion, and thought alienation; (Spanish), esquizofrenia, delirios, and inserción de pensamiento. The main source of information was peer-reviewed articles. This source was complemented by the review of books and the peer reviewed articles cited by the primary sources and the review of manuals describing diagnostic criteria for the classification of mental disorders (ICD-10, DSM-IV-TR and DSM-V). No major technical differences were found between the descriptions provided of the
24 Clinic for General Psychiatry as a PhD research fellow looking for unpublished cases18. Third, I contacted former colleagues from Chile to send me some reports on the phenomenon. Finally, I contacted Roberta Payne, former Professor of English and Latin at the university of Denver. Roberta was diagnosed with schizophrenia at a young age and over the last stage of my research she actively contributed to improve my understanding of different aspects of the symptoms from a first-person perspective19.
3.1. Thought Insertion: Main Subjective Features
Thought insertion involves the belief with the paradigmatic content [someone/something is inserting a thought with the content […] into my mind/head] (Frith, 1992; Graham & Stephens, 2000; Mullins & Spence, 2003). The phenomenological quality of thought insertion seems to differ from other types of introspective cognitive experience like hypnosis or psychokinesis where others people make the subject to think a certain thought (Gerrans, 2001). In these latter cases, although under the influence of others, subjects do not deny that the thought that pops into their stream of consciousness belongs to the influencer subject. Rather, in thought insertion: ‘others are said to think the thoughts using the subject’s mind as a psychological medium or ‘bucket’ (Sollberger, 2014, p. 590). In this sense, it is important to note that experience of thought insertion commonly occur in a context characterized by a pervasive feeling of mental passivity:
The things that are ‘thought’ in this way do not belong to the mad person as thoughts would belong to normal people. During madness, thoughts are more like inspirations or epiphanies coming from outside, that are experienced as strange and for which the mad person is not responsible. He rather feels like the thoughts present themselves to him rather than that he thinks them. He can be ‘surprised’ by thoughts. Like we would normally be surprised by thoughts that we read in a text, in the same way the mad person can be surprised by the thoughts that he reads or experiences in his own mind (Kusters, 2014, p. 105)20.
It feels like this person is using my brain to think his thoughts – just like he is seeing the phenomenon in Spanish and English publications and most of the descriptions provided in the Spanish literature were based on the descriptions originally provided in the English-language literature. 18 This internship took 4 months and it was sponsored by the Deutscher Akademischer Austausch Dienst (DAAD) Scholarship for Young Researchers. 19 I had a series of online interviews with Dr Payne in order to clarify a number of phenomenological issues regarding the occurrence of thought insertion. 20 The quotations by Kusters appear in a book originally published in Dutch. This book has not been yet translated into English. I would like to thank to Zeno Van Duppen, PhD research fellow at The University of Heidelberg for providing translation to all the quotes from this book contained in this collection.
25 world through my eyes and interfering with the world through my body. It feels like I am possessed by this person (Vosgerau & Voss, 2014, p. 536)
Contrasting with cases of hypnosis for example, Fulford (1989, p. 221) claims that in thought insertion: ‘it is the episode of thinking itself that is done to the subject’. Jaspers (1963) also points out this aspect of the phenomenon:
I have never read nor heard them; they come unasked; I do not dare to think I am the source but I am happy to know of them without thinking them. They come at any moment like a gift and I do not dare to impart them as if they were my own (my emphasis, p. 123).
Although the literature on thought insertion seems to be characterized by a number of disagreements and open questions, it is possible to identify six main aspects to this delusional belief. Any plausible theory of thought insertion should be able to make sense of the following features:
(i) Negative aspect: Patients report that a certain thought present in their stream of consciousness does not belong to them. ‘This thought is not mine’, patients will claim. In this context, it is claimed that the thought in question seems to lack the phenomenal property of ownership21. As Fish (1976, p. 39) suggests: ‘Thinking, like all conscious activities, is experienced as an activity which is being carried out by the subject […] there is a quality of ‘my-ness’ connected with thought’. However, in cases of thought insertion, it is clamed that certain thoughts are experienced as lacking this quality:
Patients report that ... the thoughts which occur in their heads [are] not actually their own. It is as if another’s thoughts have been ... inserted in them. One of our patients reported physically feeling the alien thoughts as they entered his head and claimed that he could pin- point the point of entry! (Cahill & Frith, 1996, p. 278)
Sometimes it seemed to be her own thought ‘. . . but I don’t get the feeling that it is.’ She said her ‘own thought might say the same thing . . . But the feeling it isn’t the same . . . the feeling is that it is somebody else’s . . . (Allison-Bolger, 1999, # 89)
21 This property has been named in a number of different ways: sense of mineness (Parnas, Møller, Kircher, Thalbitzer, Jansson, Handest & Zahavi, 2005a; Zahavi, 2005b), for-me-ness (Zahavi, 1999), my-ness (Frith, 1992), or meishness (Billon, 2013). Zahavi (2005a; 2011) and Grünbaum & Zahavi (2013) use the terms mineness and ownership interchangeably.
26 Lately, Billon (2013), and Billon and Kriegel (2015) claim that the alien thought in question should not be characterized only in terms of the phenomenal features it lacks. The authors suggest that apart from this reported lack of ownership, these patients experience the relevant thoughts as inserted. In this sense, the feature of ‘being inserted’ featured in the reports would not be part of an explanation offered for the occurrence of thoughts with bizarre phenomenal features. Rather, it would be part of the way alien thoughts are phenomenologically given.
(ii) Positive aspect: Patients do not only feel the relevant thought as not theirs and inserted, they also attribute it to an external agent that is not characterized as merely influencing the patients’ mental activity, but rather as actively placing a thought into their minds. As Wing, Cooper and Sartorious (1983) point out: ‘the symptom is not that he [the patient] has been caused to have unusual thoughts, but that the thoughts themselves are not his’. Along with the aforementioned negative aspect (lack of ownership), the characteristic external attribution of mental agency distinguishes thought insertion from other related phenomena such as influenced thinking (Mullins & Spence, 2003, p. 294). Patients suffering from influenced thinking report that external agents cause them to think certain thoughts. However, patients do not claim that the thought finally brought about under the influence of the external agent does not belong to them, nor do they attribute this thought to the external agent. Cahill and Frith (1996) describe thought insertion as follows:
I look out of the window and I think the garden looks nice and the grass looks cool. But the thoughts of Eammon Andrews come to my mind. There are no other thoughts there, only his. He treats my mind like a screen and flashes his thoughts onto it like you flash a picture (Mellor, 1970, p. 17).
I didn’t hear these words as literal sounds, as through the houses were talking and I were hearing them; Instead, the words just came into my head –they were ideas I was having. Yet I instinctively knew they were not my ideas. They belonged to the houses, and the houses had put them in my head (Saks, 2007, p. 29).
Thoughts are put into my mind like ‘Kill God’. It’s just like my mind working, but it isn’t. They come from this chap, Chris. They are his thoughts (quoted in Frith, 1992, p.66).
(iii) Selectivity: The nature of thought insertion is selective in two senses. First, patients do not experience all their thoughts as inserted, but just some of them (selectivity type 1). For example,
27 Gallagher (2004) claims that patients experience a sense of realization that a certain thought is inserted and this sense itself is not experienced as inserted. Second, patients experience only certain types of mental states as alien, namely, feelings, emotions, thoughts and impulses (selectivity type 2). Here are cases of inserted thoughts, feelings and emotions respectively.
The aliens were involved in a huge conspiracy against the world. Then gained even more strength. They put six rules in my head (Payne, 2013, p. 152)
When a part of my body hurts, I feel so detached from the pain that it feels as if it were somebody else’s pain (Sierra & Berrios, 2000, p. 163).
The sudden impulse came over me that I must do it [empty his urine bottle over the ward dinner trolley]. It was not my feeling, it came from the x-ray department . . . It was nothing to do with me, they wanted it done. (Mellor 1970, 17).
I cry, tears roll down my cheeks and I look unhappy, but I have a cold anger because they’re using me in this way, and it’s not me who’s unhappy, but they’re projecting unhappiness onto my brain. They project upon me laughter, for no reason, and you have no idea how terrible it is to laugh and look happy and know it’s not you, but their emotions (Mellor 1970, 17).
(iv) Specificity: This aspect concerns the content of inserted thoughts. Gallagher (2004) claims that only a certain specific kind of thought-content is experienced as alien by psychotic patients. He suggests that alien thoughts are, most of the time, associated with significant others or with themes that are affectively relevant to the patients (also see Gibbs, 2000; Vosgerau & Voss, 2014, p. 554). For example, a young male patient reported that thoughts such as ‘you are naughty’ were placed into his head by his mother22.
(v) Sense of Phenomenological Permeability: Thought insertion does not emerge in isolation but forms a cluster with other pathological phenomena such as passivity mood, thought interference, thought pressure, thought withdrawal, delusions of alien control, and thought diffusion (Cermocallce, Naudin & Parnas, 2007). All these symptoms seem to be accompanied by a sense of permeability of ego boundaries. This sense can be roughly characterized as a phenomenological demarcation between ‘me’ and ‘not-me’ (Parnas & Handest, 2003). Patients feel that the world has some degree of access to their private inner mental life; that their thoughts are publicly available and the like. While experiencing inserted thoughts, the patient’s the sense
22 This case was provided by a Chilean colleague. The patient came from a very religious family where the mother was a strong figure.
28 of ego-boundaries seems to get blurred as patients experience an external agent placing thoughts into their stream of consciousness. As Freud (1930, p. 66) already noted it: ‘There are cases in which part of a person’s own body, even portions of his mental life - his perceptions, thoughts, and feeling- appear alien to him and as not belonging to his own ego’.
(vi) Absence of a Sense of Causal Coherence: A feeling of causal coherence emerges when information concerning the triggering aspects of a certain thought is integrated to the occurrence of the thought (Martin & Pacherie, 2013). Causally integrated thoughts are experienced as ‘coherent and unified episodes of thinking’ (p. 115), and have a specific ‘phenomenology of coherence’ (p. 116). In contrast, inserted thoughts are first-personally experienced as ‘decontextualized’ or coming ‘out of nowhere’.
3.2. Disagreements Surrounding the Subjective Features of Thought Insertion
Although most people agree on the main features of thought insertion, there are a number of disagreements and open questions surrounding their particular understanding. One of the current open questions is whether the just mentioned sense of causal coherence is something different from the sense of mineness that underlies conscious thinking in non-pathological situations or if they are one and the same (Seeger, 2013). A second open question is to identify the relationship between the sense of causal coherence and the external attribution that characterize the phenomenon. Certainly, all of us experience some ‘decontextualized’ thought in everyday life without attributing it to an external agent. Therefore, it is important to clarify the role of this aspect in the general picture of the symptom.
During the construction of this compilation, it was noted that the nature of the sense of ego-boundaries has remained almost unexplored in the literature on thought insertion. Graham and Stephens (2000) claim that thought insertion cannot be explained as a case where a person suffers from a complete disruption of this sense because patients can clearly distinguish between the outside world (from where the alien thought comes from) and their own ego-boundaries (where the thought is inserted). However, from a phenomenological point of view, it is not obvious if patients can draw clear distinctions between external and internal world (Kusters, 2014). Fuchs (2005, p. 134) reports a patient who, while watching a car on the street, suddenly felt ‘kind of hard, sharp and cold’, like the car itself and its contours. What this case and cases of thought insertion seem to show is that even if there is no a total disruption of the sense of ego- boundaries, there clearly is a way in which this phenomenological boundary becomes permeable, losing its everyday robust nature. Unfortunately, little research has been conducted on this issue.
29 Regarding the selectivity of alien thoughts, it is not clear why patients only regard certain thoughts as inserted and not all of them (selectivity type 1), neither is clear why patients experience as alien only specific kinds of mental states (selectivity type 2). Pickard (2010, p. 67) proposes that the types of mental state that can be reported as alien are those that are possible to be endorsed (feelings, thoughts, and impulses). However, it is not clear if the category ‘endorsement’ is really applicable to impulses. Now, although the suggestion might explain selectivity type 2, it is not clear if it explains selectivity type 1. The suggestion seems too general because it is one thing is to suggest that certain mental states can be endorsed − and that therefore, they can also not be endorsed − but it is quite another to explain why, within a specific class of possible-to-be-endorsed mental states, just a few are regarded as alien (selectivity type 1).
In relation to this, Martin and Pacherie (2013) claim that a number of impairments in memory and attention might cause the patient to fail to integrate the information about the triggering factors of a certain specific thought, explaining this why a specific thought comes to be experienced as alien (Selectivity type 1). However, it is not clear why these different impairments only affect certain specific kinds of mental states, but more importantly, it is not clear if this suggestion can be applied to cases of impulses and feelings whose processes of production seem slightly different from the process of production of thoughts. In fact, in this context we would need to assume that the common phenomenology of impulses includes information about the impulse’s triggering factors which can be retrieved by introspection. However, this does not seem to be the case, for the lack of this type of information seems to be one of the most distinctive aspects of the phenomenology of impulses. Certainty, complementary work between these approaches might improve our general understanding of this feature of thought insertion.
Various problems regarding the understanding of the specificity of the content of inserted thoughts can be also identified. First, one can note that some of the most quoted reports in the literature on alien thoughts do not make any reference to the specific content of the thought experienced as inserted (see quotes above). Therefore, there seems to exist an important informational deficit in the context of this discussion. The second problem is that one should not conflate the issue about the specificity of the alien-thought contents with the issue about the nature of the external agents identified by the patients. In the case of the latter, it is not clear how external agents such as ‘electronic devices’, ‘three’, or ‘houses’ might have any type of relevant significance for patients. As Spence et al. (1997) report:
30 One man said that thoughts were being put into his mind and that they ‘felt different’ from his own; another said that the television and radio were responsible for different thoughts, which were tampered electrically and always felt the same way (i.e. recognisably different from his ‘own’)
However, it seems plausible to suggest that one should not rule out the existence of such a link. If it does exist, it has not been explored yet by current approaches to inserted thoughts. Apparently, the exploration of this link would require research on the relationship between delusional episodes and the patients’ biography (Gibbs, 2000). Now, when the content of inserted thoughts can be identified, some philosophers tend to claim that what makes them specific is their negative nature (Snyder, 1974; Gibbs, 2000). This suggestion is contended under the premise that reports on inserted thoughts show that it is not always the case that the delusional content has a negative nature, and therefore, we should not explain specificity in these terms. Graham and Stephens (1994, p. 104) describe the case of a girl who − allegedly − experiences the thoughts of her father and grandmother as well intentioned and helpful to her. However, Gibbs (2000, p. 199) claims that although the thought-contents experienced as alien by the young woman are not threatening or negative, certain mental baggage leading up to them might be: ‘it may be that she has an aversion to making her own decisions’ and in consequence, the character of the thought inserted by her father would have a peripheral situational negative nature, which in turn, would explain the specificity of the thought.
It is important to note that none of these suggestions deny that alien thought-contents are specific, but, rather, they disagree on the nature of this specificity. What is clear is that impersonal content such as ‘it is snowing in Stockholm’ are not likely to be found in patients (assuming the patient does not have any type of relationship with the fact of snowing in Stockholm). Alien though-contents tend to be related to the patient’s personal biography. The problem of current approaches to thought insertion is to explain how the thought with the content ‘Kill God’, for example, would be related to the patient’ set of psychologically relevant themes. In any case, none of the aspects of this debate is completely resolved yet and it seems that further research on the relationship between delusional content (or thought production), affectivity, and the patients’ personal biography is needed in this context.
Finally, one of the most recalcitrant disagreements is identified in the context of the debate about the best way of characterizing the no-ownership clause that patients tend to use while reporting thought insertion, and the relationship between this clause and the external attribution they make. What do patient mean when they say that a certain thought does not belong
31 to them? Does this lead to an automatic external attribution? Philosophers in this context distinguish between two ways in which a thought can be owned: The first form has to do with a thought simply appearing in the patient’s stream of consciousness while the second has to do with a subject identifying herself as the agent of a certain thought. In the literature, the former seems to retain the label ‘attribution of ownership’ while the latter is labelled as attribution of agency (Gallagher, 2000, 2007; Synofzik, Vosgerau & Newen, 2008; Vosgeray & Voss, 2014). However, this distinction is not uncontroversial and a number of substantial disagreements about how to best conceptualize these two forms of ownership are identified.
Zahavi (2005a) claims that the first form of ownership has an experiential nature whilst Vosgerau and Voss (2014) suggest that it is just a conceptual truth about the nature of human consciousness and that therefore, it is just not clear if it is experiential in nature. The main issue here is to define if there is such thing as a phenomenal sense of ownership in the case of thinking or if it is just a judgement, or both. The same disagreement is identified in the debate about the nature of the attribution of mental agency. Graham and Stephens (1994, p. 103) suggest that this type of ownership depends on whether a subject succeeds in attributing a certain thought or action to herself. In turn, this would depend on whether the subject is able to fit the thought or action in the picture she has of herself. In Graham and Stephen’s view, self-representation would be a necessary condition to label oneself as the author of a thought. Contrasting, Gallagher (2007) explicitly suggests that attributions of agency are based on a first-order experience of agency. Over the last years, the discussion about these two forms of ownership has become increasingly important in the cognitive sciences, philosophy of mind and philosophical psychopathology. The ongoing problem is to explain how disruptions of this form of ownership would lead to external attributions in cases of thought insertion23. Certainly, the existence of all these disagreements call for the search for alternatives and more comprehensive approaches to the occurrence of delusions of thought insertion. The different papers contained in this compilation treat different aspects of these debates and aim to contribute to the general phenomenological and conceptual understanding of this pathological phenomenon.
3.3. The Diagnostic Role of Thought Insertion in Psychiatry
Thought insertion guided the diagnosis of schizophrenia during most of the second half of the last century (Mellor, 1970; Mullins & Spence, 2003; Soares-Weiser, Maayan, Davenport, Kirkham & Adams, 2013). The origin of this diagnostic link can be tracked back to the very
23 Paper 1 of this compilation is entirely devoted to the discussion of this issue and to the development of an alternative view.
32 origin of modern psychiatric diagnosis. Emil Kraepelin suggested that psychosis falls into three types: manic depression, paranoia, and dementia praecox (current schizophrenia). Although some of these types have symptoms in common, Kraepelin suggested that each type followed a characteristic pathological course over time. The assumption underlying Kraepelin’s diagnostic work was that the accurate description of symptoms would allow researchers to decode the organic causes of mental illness and, therefore, diagnosis by symptoms would be the best way to guide researchers towards an understanding of the aetiology of mental diseases24.
Reproducing Kraepelin’s interest in symptomatology as a way of accessing the organic causes of mental illness, Kurt Schneider formally linked the experience of inserted thoughts with the diagnosis of schizophrenia. Trying to make the diagnosis of schizophrenia more operational for clinicians, Schneider (1959) elaborated a set of positive symptoms called first-rank symptoms of schizophrenia, which included: auditory hallucinations; thought broadcasting; somatic hallucinations; delusional perception; feelings or actions as made or influenced by external agents; thought withdrawal, thought interruption and thought insertion. The identification of just one of these symptoms in patients with no organic brain disease was taken as strongly suggestive of schizophrenia (Schneider, 1959; Mellor, 1970)25.
It is important to note that Schneider did not claim that this set of symptoms should be regarded as having explanatory power or theoretical significance with regard to the aetiology of schizophrenia. The use of the term ‘symptoms’ in Schneider’s system is not standard. As Crichton (1996) suggests: ‘[Schneider] is not using ‘symptom’ in the normal medical sense of evidence of a disease, but to refer to a more or less characteristic, invariably detectable feature of a purely psychopathological state-course-complex (p. 538)’. This issue should be considered when assessing the plausibility of Scheinder’s system for it seems that, most of the time; objections to this system assume that Schneider used the term in the standard way.
Kurt Schneider’s first-rank symptoms have had an immense influence on the way schizophrenia has been diagnosed in clinical practice throughout the world, especially in Germany, the UK, and other western European countries (Peralta & Cuesta, 1999; Norgaard et al., 2007). In fact, trainees are expected to be able to list all these symptoms and apply them in
24 This idea has been currently criticized by a number of clinicians and philosophers from different points of view (Sass & Parnas, 2003; Cooper, 2004; Parnas et al. 2005; Nordgaard, Arnfred, Handest & Parnas, 2008). 25 The dichotomy positive-negative dichotomy was originally developed by Hughlings Jackson as part of his theory of the nervous system. The negative cluster refers to the loss of a certain motivational or cognitive healthy function, whilst the positive cluster refers to the presence of abnormal mental activity. People without a diagnosis of schizophrenia do not typically experience ‘positive symptoms’. On the other hand, ‘negative symptoms’ such as mood disturbance or certain deficits in thought processing are experienced by people with no psychotic disorders.
33 clinical examination26. The two main current diagnostic systems have given special treatment to positive symptoms in the diagnosis of schizophrenia. The ICD-10 proposes that a normal requirement for the diagnosis of schizophrenia is the presence of a minimum of one very clear symptom (including thought insertion) (and usually 2 or more if less clear-cut) for most of the time during a period of one month or more. In practical terms, this means that if thought insertion was identified in a clear way, this was sufficient for a person to be diagnosed with schizophrenia (Mullins & Spence, 2003). Similarly, the DSM-IV-TR proposes that: ‘Only 1 Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behaviour or thoughts, or two or more voices conversing with each other’27. Since thought insertion was taken to be a bizarre-type of delusion, its presence during a month was sufficient for a person to be diagnosed with schizophrenia (Coltheart, Langdon & McKay, 2011; Shinn, Hechers & Öngür, 2013).
The special treatment given to Schneider’s symptoms in the DSM and ICD system has been severely questioned during the last years (Flaum, Andreasen & Widiger, 1998; Tandon et al. 2013). Schneider’s symptoms have been shown not to be exclusive to schizophrenia, and their reliability in distinguishing bizarre from non-bizarre delusions has been found to be poor (Mullen, 2003; Bell, Halligan & Ellis, 2006). By using a different diagnostic categorization, Carpenter et al. (1973) identified Schneider’s symptoms in patients with neurotic and character disorders. Schneider’s symptoms were also identified in patients with manic and manic- depressive disorders (Wing & Nixon, 1975). Koehler (1979) identified Schneider’s symptoms in patients suffering from mood disorders. Importantly, Peralta and Cuesta (1999) conducted a study that found that Schneider’s symptoms were highly prevalent in most forms of psychotic disorders (schizophrenic and non-schizophrenic disorders). Although Schneider’s set of symptoms are still significant to schizophrenia research, they are not specific enough for the purpose of diagnosis, as was originally thought (Tandon et al., 2013).
In the specific case of thought insertion, it has been shown that the phenomenon is not exclusive to schizophrenia. Peralta and Cuesta’s study identified experiences of thought insertion in people suffering from schizophreniform disorders (19.3% of the sample), schizoaffective
26 The specific focus on the so-called ‘positive symptoms’ of current diagnostic systems seems to have led to the neglect of the relevance that negative symptoms might have in the development or maintenance of schizophrenic symptoms. Thus, it is important to note that negative symptoms might not only handicap patients (Crichton, 1996), but also, they might have an important role in the development of positive symptoms such as thought insertion (Marwaha et al., 2014; López-Silva, 2015). 27 The DSM system establishes as criteria A the following symptoms: Delusions, Hallucinations, Disorganised speech (e.g. frequent derailment or incoherence), Grossly disorganised or catatonic behaviour, Negative symptoms (i.e. affective flattening, alogia or avolition). Thought insertion has been taken as one of the most important criterion A.
34 disorders (16.2% of the sample), mood disorders (7.2% of the sample), brief reactive psychosis (8% of the sample), and atypical psychosis (6% of the sample). Recently, the American Psychiatric Association (APA) has openly recognized that first-rank symptoms have not discriminative power to distinguish schizophrenia from other psychotic disorders (APA Report, 2013a) and as a consequence, the most recent version of the DSM (DSM-V) is moving away from the central role historically given to Schneider’s symptoms in the construction of the diagnostic criteria of schizophrenia (Tandon, 2013). As said earlier, in the DSM-IV-TR only one symptom A is required if it is a bizarre delusion (thought insertion for instance) or a special hallucination. However, the note asserting the special treatment of Schneiderian symptoms has been eliminated from the DSM-V. This means that the symptoms will be treated like any other with regards to their diagnostic importance (Tandon et al., 2013). Apart from the elimination of the subtypes of schizophrenia, the DSM-V proposes: ‘the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing)’ (APA Report, 2013a, p. 2). In practical terms, this means that thought insertion would no longer be sufficient for a diagnosis of schizophrenia by its own as it used to be. One of the current challenges in research on schizophrenia is to determine the true role of Schneider’s symptoms in its diagnosis.
4. The Philosophical Relevance of Thought Insertion: Making Sense of the Collection
As seen throughout this section, the general study of delusional phenomena, and the specific study of thought insertion raises a number of clinical and conceptual concerns. Certainly, a better understanding at the conceptual level might contribute to more comprehensive ways to appraise and judge phenomenological and empirical data concerning the occurrence of these phenomena. At the same time, empirical and clinical developments might inform the re- evaluation of some of the most fundamental ideas we have about human mind.
In recognizing the philosophical value of the study of mental pathology, this dissertation engages with five of the most fundamental disagreements underlying the occurrence of psychotic delusions of thought insertion. The five papers integrating this dissertation can be grouped in three main categories: The first three engage with a number of debates concerning the subjective structure and the process of formation of delusions of thought insertion. The fourth paper analyses the way in which thought insertion undermines a specific theory that tries to explain the subjective character of phenomenal consciousness. Finally, the fifth paper examines the more general problem about the role that delusional beliefs might play in people’s mental life. Now, let me offer more details about the aims of each one of these papers.
35 When looking closely at the most basic features of the subjective structure of thought insertion (see section 3.1.), one of the first puzzles one notices is the way in which this delusion challenges our most common conceptions about the way human beings attribute their own mental states to themselves. Humans have the ability to become aware of their own occurring thoughts and often, in doing so, we end up self-attributing them in at least three ways, thoughts are something that one undergoes (attribution of subjectivity); thoughts are something that is one owns (attribution of ownership); and thoughts are something that one has authored (attributions of mental agency). The first article of this collection titled Conscious Thoughts and Attributions of Mental Agency: An Affordance Model examines the discussion about how to best characterize attributions of mental agency. In normal cases, one attributes the agency of one’s thoughts to oneself. This might sounds obvious in a certain way. After all, who else could be the author of the thought I am undergoing? However, thought insertion challenges exactly this idea as patients claim to be first-personally aware of a thought in their stream of consciousness while attributing it to an external agent. The challenge here is that a plausible theory of attributions of mental agency should be able to explain the normal cases and the form that agentive mental attribution takes in thought insertion.
The understanding of mental self-attribution is replete with conceptual and phenomenological disagreements. In the phenomenological domain, while some people refer to their own thoughts as something they actively do, others refer to them as something that merely happens in their mind. Thus, this phenomenological disagreement makes it virtually impossible to offer a correct characterization of the way in which humans end up attributing thoughts agentially to themselves at the conceptual domain. In this first paper, I claim that we can solve this phenomenological disagreement about the way thoughts are experienced and I suggest that that the phenomenology of thoughts is fundamentally passive. This suggestion contrasts with a number of current theories about mental self-attribution that try to explain this act in virtue of the existence of first-order feeling of mental agency accompanying conscious thoughts. I deny the existence of this feeling of agency in the case of thinking but, at the same time, I claim that all thoughts of normal adult humans are phenomenologically characterized by a ubiquitous affordance of agentive attributability, namely, the possibility of a thought to be self or externally attributed in terms of agency. Thus, contrasting with current available views, my model takes attributions of mental agency to be neither the mere product of the endorsement of a full experience of self-agency accompanying thoughts (bottom-up view), nor the product of mere retrospective judgements without any type of phenomenal basis (top-down view). Instead, attributions of mental agency are the result of the integrative interaction between second-order
36 explanations and the endorsement of a first-order affordance of attributability contained in the basic phenomenology of thoughts.
Keeping the affordance model of mental self-attribution in the conceptual toolbox, the second paper titled Thought Insertion as Hybrid Delusional Beliefs engages with a disagreement within the current debate about the formation of delusions of thought insertion within a doxastic point of view. Some of the currently most dominant approaches to thought insertion characterize it as an abnormal belief rooted in anomalous experiences of different kind (Graham & Stephens, 2000; Gallagher, 2000; Martin & Pacherie, 2013; Vosgerau & Voss, 2014). However, the exact role of these experiential abnormalities in determining the exact content of the delusional beliefs is still under debate. In this context, two alternatives can be identified. On the one hand, endorsement models of thought insertion claim that the abnormal thought comprises the very content of the delusional belief, so patients simply endorse what they have experienced. On the other hand, explanationist approaches to thought insertion claim that the delusional belief emerges as an explanation for abnormal a thought with less specific content. This paper evaluates the main arguments for and against these two views. After concluding that proponents of both alternatives can partially resist some of points made by their critics, it is suggested that in order to solve this dispute we should look closer at the structure of normal beliefs and take an integrative stance towards the debate. It is proposed that single delusional beliefs have various propositional contents and that patients might arrive at some of them via endorsement and at some others via explanation. Therefore, delusions of thought insertion should be characterized as hybrid doxastic states. Finally, the paper explores some potential formulations of this hybrid model maintaining that the endorsement-explanation relationship in formation of delusions of thought insertion depends on, among other, the phenomenal nature of the thoughts of which patients are aware, surrounding perceptual conditions, and on the subject’s own psychological architecture.
The third paper of this compilation titled Psychosis and The Role of Affective Impairments in the Aetiology of Thought Insertion is devoted to a specific issue regarding the aetiology of thought insertion. Current dominant neurocognitive approaches to this debate focus on the examination of different deficits leading to the adoption of delusional beliefs (see section 1 and 2). However, these approaches seem to have neglected the role that the different impairments in affectivity that patients experience before the adoption of delusional beliefs might play in explaining the psychogenesis of this phenomenon. As a consequence of this, these approaches offer an incomplete picture of the phenomenon. In this paper it is argued that there are good conceptual and empirical reasons to think that affective impairments play a crucial doxastic role
37 in the process of formation of inserted thoughts. After examining two different formulations of the aetiology of delusions, I evaluate one specific view that attempts to integrate the role of affectivity into the aetiological picture of thought insertion and after commenting on some of the its problems, I propose an alternative deficit account based on Martin and Pacherie’s (2013) model of thought formation. Taking this model into account, I finally propose a conceptual integration between the main insights of this paper and the explanatory structure of the current two-factor view of thought insertion.
The forth paper of this compilation is titled ‘Psychosis and the Subjectivity of Consciousness’ and it is devoted to the examination of a larger discussion that overlaps with the debate about the subjective structure of thought insertion. Often, philosophers from different traditions defend a strong link between phenomenal consciousness and self-awareness. The main claim is that whenever one is aware of an experience, one can become aware of oneself as the subject of that experience. However, although we might intuitively agree on the existence of such a link, we can still disagree about its basic nature and the best way to characterize it. In this context, philosophers endorsing a self-presentational view of consciousness maintain that an experiential sense of mineness intrinsic to all conscious experiences is a necessary condition for a subject to become self-aware. Thus, the type of self-awareness naturally entailed by phenomenal consciousness would necessarily require an experiential sense of mineness to exist. In this paper argues that cases of thought insertion undermine this latter idea and that such an experiential requirement is not needed to account for the most minimal form of subjectivity entailed by phenomenal consciousness. After clarifying the content and key aspects of the debate, the two standard replies offered by the advocates of the self-presentational view are evaluated. It is concluded that although these replies add a number of interesting elements to the discussion, they do not do their job properly. In the final section, the main conclusion is strengthened by appealing to the phenomenology of cases of depersonalization and Cotard delusion.
Having sorted a number of specific issues related to the occurrence of thought insertion, the final paper titled ‘Making Sense of the Adaptive Role of Delusional Beliefs’ engages with a more general discussion regarding the nature of delusions. It is usually claimed that beliefs can be psychologically or biologically adaptive mental states. They are psychologically adaptive when they protect the subject from psychological threats. They are biologically adaptive when they help to increase a subject’s chances of survival within a specific environment. From this point of view, delusional beliefs are commonly regarded as maladaptive misbeliefs. While it is accepted that some delusions can be psychologically adaptive, it is usually denied that they can be
38 biologically adaptive. In this sense, successful adaptation would require approximating reality accurately and the beliefs that maximize a subject’s chances of survival are necessarily those that best approximate reality by capturing true states of affairs in the world, i.e. true beliefs.
The final paper of this compilation argues that there are good reasons to characterize a certain type of monothematic psychotic delusions (of which thought insertion is an example) as biologically adaptive. Thus, after distinguishing between two main types of delusions in virtue of their formation and clarifying their relationship with the two modes of adaptiveness of beliefs, I claim that in trying to make sense of the biologically adaptive benefits of psychotic delusions, one needs to understand such phenomena in the general perceptual and affective context in which some of them are adopted. Careful explorations to this issue reveals that during the period that precedes the adoption of some delusional beliefs patients gradually lose their behavioural and psychological connection with the environment and this disconnection decreases the subjects’ chances of survival. However, in characterizing delusions, current dominant approaches fail to integrate this context into the aetiological picture of the phenomena, missing the role that the adoption of some delusional beliefs might play in reorganizing the patients’ disunified and overwhelming (inner and outer) experiential world.
From this point of view, the adoption of delusional beliefs might contribute in some cases to the preservation of behavioural and psychological interaction with the environment as an attempt – however pathological − to render the patients’ reality more predictable and approachable. The idea underlying this last paper is that human cognitive systems would sacrifice doxastic accuracy in order to secure a minimally functional degree of interaction with the environment and, therefore, certain psychotic delusions might be characterized as biologically adaptive under rarefied experiential circumstances. At first, this article might look slightly off- topic; however, this is not the case. The main motivation for engaging with the general issue regarding the adaptiveness of delusions emerges from the exploration of the specific context in which delusions of thought insertion are adopted. From such an examination it was observed that most current dominant approaches to monothematic delusions also neglect this context and therefore, a sufficiently justified move was to transfer the argument in the specific treatment of the adaptiveness of thought insertion to the general debate about whether monothematic delusions can be taken as biologically adaptive under certain circumstances.
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44 Conscious Thoughts and Attributions of Mental Agency: An Affordance Model
Summary
Humans not only have the ability to consciously experience their own thoughts, but, in doing so, can also attribute agency to these thoughts. I shall call this act attribution of mental agency. The analysis of this issue in philosophy is replete with conceptual and phenomenological disagreement. In the phenomenological domain, while some people refer to their own thoughts as something they actively do, others refer to them as something that merely happens in their mind. In the conceptual domain, the aforementioned phenomenological disagreement makes it very difficult to offer a correct characterization of the way in which humans end up attributing thoughts agentially to themselves. In this paper, I argue that the phenomenology of thoughts should be fundamentally characterized as passive, i.e. as not involving any type of first-order feeling of mental agency. But, at the same time, I claim that all thoughts of normal adult humans are phenomenologically characterized by a ubiquitous affordance of agentive attributability, i.e. the possibility of a thought to be internally or externally attributed in terms of agency. In contrast with current available views, the affordance model defended here takes attributions of mental agency to be neither the mere product of the endorsement of a full experience of self-agency accompanying thoughts (bottom-up view), nor the product of mere retrospective judgements without any type of experiential basis (top-down view). Rather, attributions of mental agency are the result of the integrative interaction between second-order explanations and the endorsement of a first-order affordance of attributability contained in the basic phenomenology of thoughts. Thus, by adopting an integrative posture, the affordance model of agentive mental attributions should be able to gain better dialectal traction than either of the bottom-up or thetop-down views in current literature.
Acknowledges: I would like to thank Prof Dr Thomas Fuchs, Dr Tom McClelland, and Dr Leo Tarasov for useful comments on earlier drafts of this article.
45 For it is so evident of itself that it is I who doubt, who understands, and who desires… René Descartes
It is perfectly true, as philosophers say, that life must be understood backwards… Soren Kierkegaard
I don’t need to be in agreement with what I think Carlos Caszely
1. From Self-Attributions of Bodily Movements to Self-Attributions of Thoughts
When Agustin’s body (or parts of it) moves, there is a basic sense in which one may ask whether he is aware of this episode occurring intentionally or unintentionally. Agustin may become aware of his body moving intentionally when, for example, kicking a ball during a football game. In contrast, he may become aware of his body as moving unintentionally when, while trying to kick the ball, being pushed away by one of the members of the rival team. Ignoring certain complexities, we can say that philosophers often agree that what distinguishes the former case from the latter is the existence of a distinctive self-attribution of bodily agency28, i.e. the act of attributing the initiation or authorship of a certain bodily movement to oneself. While in the former case Agustin attributes the authorship of the relevant bodily movement (kicking) to himself, in the latter case he does not. In Bayne and Pacherie’s (2007) words, Agustin’s kicking counts as a case of agentive awareness because it involves Agustin becoming aware of himself as an agent of the relevant bodily movement.
The dominant view in the discussion about attributions of bodily agency rests on two phenomenological assumptions: first, that there is a crucial difference between what it is like to move intentionally and what it is like to move unintentionally, and second, that the phenomenology of bodily actions is fundamentally active. Mere bodily activities, such as being pushed away, spams, reflexes, and so on, are phenomenologically distinguishable from bodily actions (goal-directed bodily movements) because they feel different at the most basic experiential level29. Thus, certain bodily movements are self-attributed as actions of oneself because they feel that way. The basis in which the act of self-attributing a bodily movement is built upon is usually characterised as a sensorial component contained in the representational
28 This notion is labelled in different ways by different authors: ‘Attribution of Agency’ (Stephens & Graham, 2000), ‘the sense of agency’ (de Vignemont & Fourneret 2004; Gallagher 2000, 2014; Marcel 2003; Peacocke 2003); ‘control consciousness’ (Mandik 2010), and ‘action consciousness’ (Prinz 2007). The relevant issue is that these authors make reference to the existence of a distinctive attribution that distinguishes voluntary from involuntary bodily movements although they might disagree about the nature and architecture of this attribution. 29 For a recent critique of this view on agentive bodily awareness, see Mylopoulos (2015).
46 structure of certain bodily movements30 (see Gallagher, 2000; 2007a; 2007b; Frith, 1992; Bayne & Pacherie, 2007; Bayne, 2011, among many others). Here self-attributions of bodily agency arise as a matter of endorsing this first-order experiential information contained in certain bodily movements. The primary ingredient of attributions of bodily agency is an actual experience or sense of agency that accompanies certain bodily movements. Premised on this idea, the architecture of self-attributions of bodily agency is predominantly characterized as having two levels, one more fundamental than the other:
The ‘vehicles’ of agentive self-awareness are often more primitive than judgments. Think of what it is like to push a door open. One might judge that one is the agent of this action, but this judgment is not the only way in which one’s own agency is manifested to oneself; indeed, it is arguably not even the primary way in which one’s own agency is manifested to oneself. Instead, one experiences oneself as the agent of this action (Bayne & Pacherie, 2007, p. 476)
This bottom-up view suggests that, on a first-order level, a sensorial experience of agency embedded into the phenomenal structure of certain bodily movements (bodily actions) represents the subject as the author of the movement. This experience would figure in the natural phenomenology of motor actions. On a second-order level, more robust higher-order judgements of self-agency are based on the first-order experience of self-agency. It follows that the representational content of these more robust judgements of bodily self-agency is acquired from the representational content of the first order sensorial experiences of agency (Gallagher, 2007a, p. 348).
Transferring a number of ideas from the above debate into the domain of conscious thinking, recently, a number of authors have suggested that we can also talk about self- attributions of agency in the case of thoughts (Frith, 1992; Graham & Stephens, 1994; Campbell, 1999; 2002; Stephens & Graham, 2000; Gallagher, 2000; 2013; 2014; Proust, 2009; Vosgerau & Voss, 2014; among many others). A self-attribution of mental agency refers to the act of attributing a thought to oneself as one being its author or initiator (Stephens & Graham, 2000; Gallagher, 2000; 2007a; De Hann & de Bruin, 2010; Vosgerau & Voss, 2014, among many others). Some of the most popular models aimed at explaining this brand of self-attribution involve the establishing of a direct parallelism between motor actions and thoughts (see Feinberg, 1978; Frith, Blackemore & Wolpert, 2000; Campbell, 1999; Ito, 2008). However, it has been
30 This view is expressed by Bayne (2011) when he claims that: ‘Just as we have sensory systems that function to inform us about the distribution of objects in our immediate environment, damage to our limbs, and our need for food, so, too, we have a sensory system (or systems), whose function it is to inform us about facets of our own agency’ (p. 356).
47 argued that such a parallelism leads to a number of intractable problems (Proust, 2009; Vosgerau & Voss, 2014; see section 4 of this article). In fact, it is not even clear whether the just aforementioned dominant view of bodily agency can be transferred into the domain of conscious thinking without serious conceptual and phenomenological complications.
One of the most serious difficulties for the establishment of any type of parallelism between motor actions and thoughts is that, in the latter case, we are not referring to sensorial experiences but, rather to cognitive experiences, and it is unclear whether we can use any model that strongly relies on the sensorial nature of bodily actions to explain how we self-attribute agency to our thoughts (Synofzik et al. 2008). A second crucial difficulty is that – unlike the bodily case – there seems to be no agreement about how to best characterize the primary phenomenology of thoughts in light of the issue about agency. While some people refer to their own thoughts as something they do (active phenomenology), others report them as something that merely happens to them (passive phenomenology). This situation contrasts with the bodily case, where bodily actions are always referred to as something people do (otherwise they would be mere involuntary bodily movements). This phenomenological disagreement brings us to a conceptual problem. Again, unlike the case of motor actions, there is no dominant view about the best way to characterize the production of our attributions of mental agency. Certainly, an appropriate clarification of the phenomenology of thoughts would lead to the clarification of this conceptual problem. Finally, the whole debate about agency for thoughts is intensified in light of the phenomenology of psychotic symptoms such as thought insertion where patients attribute the agency of first-personally accessible thoughts to external agents of different nature31 (see Mullins & Spence, 2003).
All these difficulties justify a specific treatment of the issue about agentive attributions of thought as different from the discussion regarding attributions of bodily agency. The primary aim of this paper is to engage further with all these problems in order to outline an alternative view on the way adult humans attribute agency to their own phenomenally available thoughts. After arguing that the phenomenology of thinking should be characterized as fundamentally passive, and that current explanatory models of attributions of self-agency are inadequate, I suggest that all thoughts of normal adult humans are phenomenologically characterized by a ubiquitous affordance of agentive attributability, i.e. the possibility of a thought to be self or externally
31 All these discussions should be distinguished from the metaphysical debate about whether thoughts are mental actions (see Peacocke, 2003; O’Brien & Soteriou, 2009). This latter debate is about what thoughts are, while ours concerns the way in which thoughts are experienced and how we can self-attribute those thoughts. These are not metaphysical matters. Rather, they concern different issues about what it is like to experience thoughts.
48 attributed in terms of agency. In contrast with current available views, according to the affordance model, attributions of mental agency are the product of neither the endorsement of a full experience of self-agency that accompanies thoughts (bottom-up view), nor of retrospective judgements without phenomenal basis (top-down view); rather; they are the result of the interaction between second-order explanations and the endorsement of first-order phenomenal features of phenomenally available thoughts. In this sense, agentive mental attributions are a potential act that is embedded in the most basic phenomenology of thoughts.
2. Experiencing and Self-Attributing Thoughts: A Land of Disagreements
2.1. The Phenomenal Character of Thoughts: A Liberal Stance
Consciousness involves a number of different types of sensory conscious states. We see, hear, smell, taste, and touch things; we also have bodily and affective states of different kind. All these kinds of conscious states enjoy a distinctive phenomenal character, i.e. there is something that it is like to be in those states or, in other words, they feel in a distinctive way (Nagel, 1974). However, consciousness also includes cognitive experiences, like thoughts. It is an ongoing debate whether thoughts enjoy a distinctive non-sensory and purely cognitive phenomenal character32. As explained by Bayne and Montague (2011), advocates of a liberal view accept that the domain of phenomenology can be extended beyond the sensory and claim that conscious thoughts possess a distinctive and proprietary cognitive phenomenology33. As Strawson (1994) claims:
[T]he experience of seeing red and the experience of now seeming to understand this very sentence, and of thinking that nobody could have had different parents ... all fall into the vast category of experiential episodes that have a certain qualitative character for those who have them as they have them (p. 194).
In contrast, those defending a conservative view claim that thinking has no distinctive non-sensory phenomenal character (Nelkin, 1989; Tye, 1995)34. Non-radical conservatives claim that thoughts might have a certain kind of quasi-phenomenal character acquired in virtue of the
32 For a complete summary and discussion of the many positions on this issue, see Bayne & Montague (2011). 33 Pitt (2004) suggests that: ‘in addition to arguing that there is something it is like to think a conscious thought, I shall also argue that what it is like to think a conscious thought is distinct from what it is like to be in any other kind of conscious mental state, and that what it is like to think the conscious thought that p is distinct from what it is like to think any other conscious thought’ (p. 2). 34 Bodily sensations and perceptual experiences are prime examples of states for which there is something it is like to be in them. They have a phenomenal feel, a phenomenology, or, in a term sometimes used in psychology, raw feels. Cognitive states are prime examples of states for which there is not something it is like to be in them, of states that lack a phenomenology (Braddon-Mitchell & Jackson 2007, p. 129).
49 sensory states with which the relevant thoughts are associated35. For example, when having a visual experience of a dog one might think ‘that is a pretty ugly dog’; this latter state is a type of thought and – from a non-radical conservative point of view - it would acquire some kind of phenomenal character only in virtue of it being related to the visual experience of the dog. In contrast, radical conservatives suggest that there is no such thing as a purely and distinctive cognitive phenomenology whatsoever and that thoughts are conscious in a non-phenomenal way.
In the rest of this article, I assume a liberal reading of the phenomenology of thinking, accepting that episodes of conscious thinking have a distinctive cognitive phenomenal character over and above the objects they represent and the sensory modalities with which they might be associated (see Siewert, 1998; Pitt, 2004; Proust, 2009; Strawson, 1994; 2003; Horgan & Tienson, 2002; Zahavi, 2005). After all, it seems plausible to claim that there is a basic sense in which what it is like to think that P feels distinctively different from what it is like to see, smell, or touch P, independently of the properties of P and the sensory modalities through which P is given.
2.2. Modalities of Mental-Self Attribution: Subjectivity, Ownership, and Agency
There are different ways in which we can attribute the thoughts we experience to ourselves; the most fundamental way in which we can do this is by referring to them as mental states to which we simply have first personal access, i.e. mental states that we are simply undergoing or that are happening in our subjective space. This is to recognize that the way I access to my own thoughts is exclusive in the sense that others cannot access to them in the same way. The idea here is that there is something that is like for me to experience thoughts and it is in this sense that I cannot be wrong about whose thoughts they are; they are my thoughts because I am the one aware of their occurrence; I am the one undergoing them. Period. This seems to be the most primitive modality of self-attribution entailed by the phenomenally conscious character of thoughts. Let’s call this the attribution of subjectivity.
A number of authors have characterized the notion of mental self-attribution as the idea that my thoughts are my own because I can experientially claim them to be in my stream of consciousness (Gallagher, 2000; 2014; de Hann & de Bruin, 2010; Zahavi, 2005; Grünbaum & Zahavi, 2013). The idea is that thoughts are mine because they feel as given in my stream of consciousness or ‘in my mind’. To put it another way, the claim is that I feel that I, so to speak,
35 About this, Carruthers (2005) claims that: ‘our thoughts aren’t like anything, in the relevant sense, except to the extent that they might be associated with visual or other images or emotional feelings, which will be phenomenally conscious by virtue of their quasi-sensory status (pp. 138-139).
50 own the location or space in which the phenomenally available thoughts are given to me. This formulation can be observed in Grünbaum and Zahavi’s (2013) discussion of delusions of thought insertion:
When a subject who experiences thought insertions or delusions of control reports that certain thoughts are not his thoughts, that someone else is generating these thoughts, he is also indicating that these thoughts are present, not ‘over there’ in someone else’s head, but within his own stream consciousness, a stream of consciousness for which he claims ownership (p. 235, my emphasis)
Rather than thinking of the stream of consciousness as the location of a thought, it is more plausible to think of it as the way in which we represent the occurrence of phenomenally available thoughts, or as the way in which phenomenally conscious episodes simply occur. This idea is often referred as the unity of consciousness, and all what it entails is that, when I focus my attention on them, phenomenally available experiences seem to be given as in a unified stream (Bayne & Chalmers, 2003; Bayne, 2010). The claim implies neither that mental states are experientially given to me as in my stream nor that one has direct experiential access to this stream as the location of one’s thoughts. Arguably, here the conclusion that mental states are experientially given to me as in my own stream requires a further inferential, namely, ‘these experience are given as in a stream; I only have one stream of consciousness, and that stream is my own’ (see Vosgerau & Voss, p. 535). Thus, the notion of a stream of consciousness would be related to the role of attention in organizing phenomenally available experiences. However, this would imply that we do not have a full experience of the stream of consciousness, which is what the aforementioned characterization requires. In any case, it is important to note that it is one thing to say that the mental states I have phenomenal access to are given as in a stream when I focus my attention to them, and quite another is to say that those experiences are given to me as in a stream that is felt as my own. One does not seem to have direct phenomenal access to one’s stream of consciousness as such; rather, our phenomenally available experiences are represented as being given in a stream.
Coming back to main aim of this section, it is crucial to distinguish attributions of subjectivity from attributions of mental ownership. While the former refers to the self-attribution of a mental state as something I am undergoing, the latter refers to the attribution of a mental state undergone by me as my own state (see Zahavi & Parnas, 1998; 2011; Gallagher & Zahavi, 2007). Often, the notions of subjectivity and ownership are conflated under the claim that every mental state that is phenomenally available to me is experientially given to me as my own mental
51 state (Zahavi & Kriegel, 2015). On this formulation, there would exist an experiential sense of mineness attached to every single mental state present in one’s stream of consciousness (Zahavi, 2005; Gallagher & Zahavi, 2008; Grünbaum & Zahavi, 2013). An attribution of ownership would arise as the mere endorsement of this phenomenal feature of mental states (Zahavi, 2005).
However, it is important to note that subjective phenomenal availability (subjectivity) does not necessarily entail mental ownership. The phenomenology of delusions of thought insertion provides prima facie evidence that subjectivity and ownership are two separable types of self-attributions, and that one does not necessarily imply the other36. Thought insertion patients are phenomenally aware of an alien thought that does not feel as theirs: ‘the subject experiences thoughts which are not his own intruding into his mind. The symptom is not that he has been caused to have unusual thoughts, but that the thoughts themselves are not his’ (Wing et al., 1983; also see Mullins & Spence, 2003). Indeed, one of the most puzzling aspects of this delusion is that some phenomenally available thoughts occurring within the subject’s stream of consciousness are not felt as being the subject’s own thoughts (Bortolotti & Broome, 2008). If anything, thought insertion shows that certain thoughts lack the alleged sense of ownership and therefore, that attributions of subjectivity do not automatically entail a person self-attributing a thought as her own thought (Martin & Pacherie, 2013). In fact, thought insertion patients end up ascribing the alien thoughts present in their own stream of consciousness to external agents of different nature, such as persons (e.g. TV celebrities, relatives; see Frith, 1992), electronic devices (e.g. TVs, radios; see Spence et al. 1997), collective groups (e.g. aliens, the government, secrets societies; see Payne, 2013), surrounding inanimate entities (e.g. houses, trees; see Saks, 2007), among many others (see also Mellor, 1970; Mullins & Spence, 2003)37. Thought insertion shows that it is one thing to merely undergo a thought, and quite another are the ways in which I can do this (as mine, as not mine, and so on).
In relation to this, Martin and Pacherie (2013) have recently suggested that independent evidence for the separability of attributions of subjectivity and ownership can be found in the phenomenology of thought broadcasting, another positive symptom of psychosis (Schneider, 1959). Patients suffering from this delusion experience their own thoughts as escaping silently from their mind/head; these thoughts ‘may or may not be available to other people’ (Pawar & Spence, 2003, p. 288). The authors suggest that: ‘in thought broadcasting, therefore, patients have introspective access to their broadcasted thoughts, but these thoughts are not experienced as
36 Paper 4 of this compilation engages further with this issue. 37 As a patient reports: Thoughts are put into my mind like ‘Kill God’. It’s just like my mind working, but it isn’t. They come from this chap, Chris. They are his thoughts (quoted in Frith, 1992, p.66).
52 localized within their own psychological boundaries’ (Martin & Pacherie, 2013, p. 113). In other words, the broadcasted thoughts are not experienced themselves as exclusively in my private subjective space. From this, Martin and Pacherie conclude that thought broadcasting shows that one could have an attribution of mental ownership without necessarily having an attribution of subjectivity.
However, it is not entirely clear whether we can draw such a conclusion from cases of thought broadcasting. Someone might reply that this conclusion is not guaranteed because the experience of my own thoughts being broadcasted is still part of my subjective field of awareness; it is still an experience that I am undergoing, so an attribution of subjectivity might be preserved. Perhaps, an additional distinction is in place: what this delusion shows is that the sense of privacy usually attached to my phenomenally available mental states can get disrupted. In a certain way, this delusion would also show a disruption (in terms of permeability) in the sense of ego- boundaries, as subjects have first personal awareness of mental states that are beyond their private psychological boundaries.38 A safer conclusion in this context would be that attributions of ownership seem to necessarily depend on attributions of subjectivity, but the reverse is not the case. It seems phenomenologically impossible to attribute a thought as my own thought without this thought being something I am subjectively undergoing. However, it is possible to self- attribute a thought as something I am undergoing without feeling it is my own thought, as cases of thought insertion suggest.
Some people might resist this idea by appealing to cases of thought withdrawal where patients claim that some of their own thoughts have been stolen or removed from their mind/head by external agents (Schneider, 1959; Koehler, 1979). It might be concluded that these patients are able to self-attribute the thoughts in question in terms of ownership (their own thoughts), but not in terms of subjectivity (not undergone by them). However, it is not clear whether this conclusion is guaranteed. For example, we might suggest that this line of thought misses the temporal aspect of the formation of this delusion and that thought withdrawal does not show that it is possible to have an attribution of ownership without an attribution of subjectivity. The idea would be that the main phenomenological datum in these cases is that patients experience a certain thought ceasing in their heads which may be interpreted as the thought being removed or stolen by some external
38 The concept of ‘ego-boundaries’ refers to a phenomenological demarcation between ‘me’ and ‘not-me’ that characterizes our mental life (Parnas & Handest, 2003). About this, Freud (1930) observes that: Pathology has made us acquainted with a great number of states in which the boundaries lines between ego and the external world become uncertain or in which they are actually drawn incorrectly. There are cases in which part of a person’s own body, even portions of his mental life-his perceptions, thoughts, and feeling- appear alien to him and as not belonging to his own ego (p. 35)
53 agent (Boydell et al. 2007). Patients would add the ‘stealing’ part of the delusion as an explanation for the ceasing of a certain thought. Thought withdrawal would refer to a thought that was in the patient’s head and that is not longer in it. Thus, the reported attribution of ownership would be about a thought that was had by the patient and, when she had it, subjectivity and ownership happened simultaneously.
A possible reply to this would be to say that patients experience their own thoughts as being undergone by whoever it is that withdraws them. However, first, it is not clear whether this is actually the case and, second, the experience of the thought undergone whomever it is that withdraws them is still an experience undergone by the patient, so a certain attribution of subjectivity might be retained. The crucial issue here is that it is not clear whether the external agent is part of the representational content of the experience leading up to the formation of this delusion. Certainly, a clarification of this latter issue might contribute to a better understanding of the debate whether subjects can attribute ownership to thoughts without attributing subjectivity. In any case, all I wish to show here is that subjectivity and ownership are two separable modalities of self-attribution and that it is plausible to say that the latter depends on the former, but the reverse is not the case.
Having clarified these modalities of self-attribution of thoughts, I shall understand self- attributions of mental agency as the act of attributing the property of being authored by one to a thought phenomenally available in one’s stream of consciousness. It seems plausible to suggest that, in a certain way, this modality of attribution seems to be the most demanding in introspective terms, as it seems to require the act of making sense of causal information about the occurrence of phenomenally available thoughts (Campbell, 1999). Another crucial issue is that cases of thought insertion show that thoughts to which one has first-personal phenomenal access can be attributed to external agents. For example, as a patient reports: ‘the thoughts of Eammon Andrews come to my mind. There are no other thoughts there, only his. He treats my mind like a screen and flashes his thoughts onto it like you flash a picture’ (Mellor, 1970, p. 17). Therefore, it is possible to distinguish between self-attribution and external-attributions of mental agency. Any account of the formation of attributions of mental agency should be able to explain these two modalities. In the rest of this paper, I will focus on this modality of mental self-attribution.
2.3. The Phenomenological Passivity of Thoughts
Once we distinguish attributions of mental agency from other modalities of mental attribution, the next step is to engage with the discussion about how to best characterize the most
54 basic phenomenology of thoughts in light of the question about agency. A natural way of approaching this issue is by examining the way we commonly refer to our thoughts in everyday life. Here, things get considerably complicated, as there is an apparent disagreement about the way in which different subjects do this. In the bodily case, it is agreed that attributions of bodily agency are fundamentally based on experiences with active phenomenology, and this is also displayed in the forms in which people refer to their own bodily actions in everyday life. However, the problem in the context of thinking is that:
Some people see their successive thoughts as something they are acting upon in their contents and even in their formal relations […]. Others, however, take thinking to occur mostly outside of awareness. Beliefs and desires occur to us; reasoning does not seem to leave room for choices or stylistic variations. Thoughts seem sometimes to be entertained and to determine our behaviours with no associated subjective awareness, let alone any sense of agency (Proust, 2009, p. 253-254, my emphasis).
The primary issue here is that while some people tend to refer to their own thoughts in an agentive way, others seem to do so in a fundamentally passive way39. Certainly, it is difficult to know how to reconcile the agentive and the passive camp, as they seem to reflect two different intuitions about the experiential nature of thinking, and such intuitions can be highly dependent on the cultural context in which those cognitive experiences are reported. This is similar to, as Searle (1983) puts it ‘arguing for the existence of pains: if their existence is not obvious already, no philosophical argument could convince one’ (p. 44). Nevertheless, it seems that this apparent phenomenological disagreement can be solved40.
Putting aside any type of conceptual pre-conceptions, we find that a careful examination of the reports of our own thoughts reveals that they have a fundamentally passive phenomenology. Experientially, our thoughts are something that ‘happens’, are ‘undergone’ or are ‘entertained’, so they should not be characterized as having an active phenomenology in the same way bodily
39 Again, this phenomenological disagreement should not be confused with the metaphysical discussion about whether thoughts are or are not mental actions (O’Brien & Soteriou, 2009, p. 2). For people like O’Shaughnessy (2000), and Peacocke (2007), thoughts are necessarily mental actions. In contrast, people like Strawson (2003) are skeptical about this idea. Although related, the phenomenological and metaphysical debates are distinct. One can uncontroversially claim that thoughts are actions while denying the existence of any impression of agency and the opposite position is also possible. In this article I take these two disagreements to be argumentatively independent of one another. 40 A preliminary alternative in this context is to claim that both camps get their phenomenology right. While defenders of a cognitive agentive phenomenology experience their own thoughts in a certain way, advocates of a cognitive passive phenomenology would experience them in a different way, and both camps would be accurately reporting what their own thoughts are like. However, as McClelland (2015) rightly points out, although this kind of way out seems attractive - because it makes everybody right - we should agree that it is a tremendously implausible alternative. The more likely situation is that both camps enjoy the same type of experience but at least one of them is mixing things up while reporting thoughts. Here I shall explore a more plausible alternative.
55 actions are claimed to have41. Some people might resist this claim by suggesting that thinking encompasses all sort of cognitive experiences, such as judging, desiring, visualizing and so on, and that while some of these experiences can feel passive (being the basis for a certain type of passive report), some of them can be characterised as active or agentive from an experiential point of view (being the basis for agentive types of report). However, this would imply that thoughts contain experiential information about the type of thought they are, an idea that sounds very odd. Thoughts do not contain information about their specific typology; rather, they seem to afford a certain typology depending upon the context of the other mental activities in which they are brought about. Thus, even those thoughts reported by subjects using apparent agentive clauses may be interpreted as fundamentally passive from an experiential point of view.
Consider the cases that Strawson (2003) comments on here:
Thought, it seems, is often a matter of things just happening, and the passive or non- agentive nature of the ordinary experience of thought is vividly expressed in many of our idioms: 'I realized that p', 'It struck me that q', 'I had an idea', 'I noticed that r', 'Then I understood', 'The scales fell from my eyes', 'The thought crossed my mind'; 'I saw the answer',' It suddenly came to me', 'It occurred to me - it dawned on me', 'I remembered that s', 'It hit me that t', 'I found myself thinking that u', 'v!-of course-how stupid of me!' (p. 230, my emphasis)
The way in which these different types of thoughts are reported in everyday life seems to leave little room for agentive considerations from an experiential point of view. In all these cases, thoughts are a matter of spontaneous appearance in one’s stream of consciousness where no clear agentive experiential elements can be identified. It is highly dubious to claim that, while thinking, one becomes aware of one’s own thoughts as something that one is voluntarily producing. Rather, it seems more plausible to characterize thoughts as something that happens to us. As de Hann and de Bruin (2010) rightly point out ‘the default [phenomenological] mode in thinking is precisely not an explicit and wilful generation of thoughts’ (p. 383).
Now consider some ostensively more agentive cases:
'I've worked it out,' 'I judged that p,' 'my considered judgement is that p,' 'after reflection I endorsed the view that q,' 'I reasoned that r,' 'I decided that s,' 'I came to the conclusion that t,' 'I assented to the proposition that u,' 'I speculated, hypothesized, that v, and judged that if v, then w,' 'I accept that x.' (Strawson, 2003, p. 230)
41 I would like to thank Prof Dr Thomas Fuchs for insightful conversations about this issue.
56 Here some people might suggest that – experientially – thoughts are a matter of action. Judging that P, working out that P, reasoning that P, and so on, might express something that one is doing in this sense. However, even though it is necessarily true that one is doing the judging, reasoning, etc., it is just not the case that this feels as something that one is doing. Even in the above instances it is not the case that thoughts enjoy an active phenomenology. When one claims that one is judging that P, one seems to be taking a retrospective position towards a thought- content that appears in one’s field of awareness. Importantly, as proposed by Wegner (2002, p. 330), the tendency to attribute control to oneself is a trait of personality that seems to extend further in some people than in others. Consequently, these more agentive reports (considering, judging, reflecting, endorsing, etc.) seem to reflect the adoption of certain attitudes or having a certain temperament towards certain thought-contents present in a subjects’ stream of consciousness (and also in the context of other accompanying mental activities). Thus, expressions such as ‘working out that P’, ‘reasoning that P’, ‘judging that P’ and so on, arise as a retrospective position taking towards a thought-content phenomenally available in the subject’s field of awareness.
Another way of arguing that thoughts have an active phenomenology is by suggesting that attending a thought might imply some experiential impression of agency. However, this suggestion is not very helpful, as the act of attending to the thought that P is different from the moment of appearance of the thought that P in one’s stream of consciousness. After all, we only attend to thoughts that are already available in our stream of consciousness so attention has little to do with the primary phenomenological way in which thoughts occur. Arguably, the act of attending to the thought that P might feel agentive or active; it might have an active phenomenology if you prefer it. However, this does not imply that the appearance of the thought that P in my stream of consciousness feels active; the latter is still a passive experience.
A final possible reply is to suggest that ‘thinking, like all our actions, is normally accompanied by a sense of effort and deliberate choice as we move from one thought to the next’ (Frith, 1992, p. 81). First, it is just not true that this alleged sense of effort accompanies all our thoughts. Second, this suggestion makes a distinction between thinking and thought that is directly analogous to the distinction between movements (thoughts) and execution of movements (thinking). In fact, this confusion is present in a number of places in the literature about thought insertion for example (e.g. see Stephens & Graham, 2000; Gallagher, 2004; 2007a; Proust, 2009; Langland-Hassan, 2008). In the debate about bodily agency, attributions of self-agency are associated with being the author of a certain bodily movement and with the execution of that
57 bodily movement (Tsakiris & Haggard, 2005; Moore et al. 2010). This distinction does not seem to apply to thoughts because it is implausible to say that we ‘execute’ thoughts in the same way we execute bodily movements. In fact, it is not clear whether we can really draw a phenomenological distinction between thinking and thought in this sense; if I say that I am executing the thought that P, the thought that P is already present in my stream of awareness. It is true that when one experiences a thought, one does not only have access to its content, but also to surrounding triggering information, ‘although this information may sometimes be difficult or even impossible to retrieve’ (Martin & Pacherie, 2013, p. 115). However, this does not imply that the process of thinking is phenomenologically given as the execution of a thought, as something for us to claim mental agency of. In this context, Vosgerau and Voss (2014) have recently claimed that what we call thinking are the many mechanisms that bring about thoughts, and that these mechanisms have an automatic and subpersonal nature.
However, there is a way in which one can think of thinking in a subjective way. Humans can initiate specific trains of thoughts, and thoughts can often be retrospectively attributed as integrating some of these trains. In making these attributions, subjects make connections between the relevant thoughts and other contingent thoughts that are phenomenally available. Here, I shall reserve the term ‘thinking’ for the retrospective activity of keeping track of the relation between individual thoughts and other thoughts that integrate the same train (see Bayne, 2013, p. 13-15). Arguably, here ‘thinking’ – as I am defining it – might be part of the explanation for attributions of self-agency for individual thoughts (see for example, Campbell, 1999). I will leave tis suggestion until sections 4 to 6 below. Here I shall note only that, at least in the context of the present debate, it is more precise to talk about attributions of agency for thoughts rather than attributions of agency for thinking. More important is the fact that, in order to get at the notion of attributions of mental agency, most of the time philosophers refer to notions like ownership, mineness, and agency indistinctively (see next section). Often, authors switch from one to the other without really taking into account that those terms seem to refer to distinct aspects of our mental life42.
Here, it is important to note that sometimes I might feel a sense of effort when initiating a certain train of thoughts but this amounts to neither feeling a sense of effort for thoughts, nor feeling an experience of agency for the specific train of thoughts. In these cases, I don’t experience myself as volitionally producing the individual thoughts that constitute the specific
42 This issue is characteristic of Gallagher’s and Zahavi’s treatment of the notion of self-attribution (Zahavi, 2005; 2013; Gallagher, 2000; 2004; 2007; 2013; 2014).
58 train; rather, I feel ‘a kind of concentration, a funnel to direct the upcoming thoughts in a certain direction’ (de Hann & de Bruin, 2010, p. 383). When one says ‘Shut up! I‘m thinking’ one still experiences the different thoughts appearing in one’s stream of consciousness passively, without any type of full experience of self-agency attached to them. Then, when one finds the answer and says ‘got it!’, one still feels this thought as passive. The fundamental distinction here is that a sense of effort might be a property that can accompany the awareness of thinking something through, but this sense of effort should not be confused with individual thoughts having an active phenomenology. In reality, most of the time, the final outcome of a train of thought, which is an individual thought, is experienced passively and with a subtle feeling of surprise or realization. Therefore, we should still think of thoughts as having a passive phenomenology.
The point I’ve made in this section is that there are no compelling phenomenological grounds to claim that a full phenomenal experience of self-agency accompanies the occurrence of normal thoughts, as it does in the case of bodily actions. Although the clauses that some people use to refer to certain thoughts might make them look like something deliberate, the actual experience of having thoughts is passive. Thoughts appear in our stream of consciousness like dandelions. From this point of view, the phenomenology of thinking should be fundamentally defined as a passive kind of phenomenology. Thoughts are primarily not experienced as actions, but as activities of our mind. Here I agree with Strawson (2003, p. 231) when he claims that ‘some of us are much more likely than others to experience what he [Wegner, 2002] calls an “emotion of authorship” in reason, thought and judgement. I never experience anything of the sort’. Strawson seems to rightly capture the most fundamental phenomenology of thoughts without being a victim a theoretical bias in favour of the agentive analysis of the phenomenology of thoughts.
However, our everyday intuitions about mental agency are very strong. Consider the case of unbidden thoughts i.e. those thoughts that ‘strike us unexpectedly out of the blue’ (Frankfurt, 1976, p. 240). Although unbidden thoughts are not accompanied by any type of experience of self-agency whatsoever, and that they are accompanied by a feeling of subtle surprise that distinguish them from the normal passivity of thoughts, we do self-attribute unbidden thoughts in terms of agency. Another case is daydreaming. While daydreaming, one is immersed in one’s own thoughts without feeling any type of experience of agency towards them, without feeling an active phenomenology. Yet one retrospectively self-attributes those thoughts in terms of agency. These cases seem to suggest that one might be able to make sense of certain thoughts in purely retrospective inferential terms, i.e. as a stance taken towards passive thoughts not necessarily
59 grounded in any type of experiential information (as it seems to be the case with unbidden thoughts). This idea would be consistent with a passive view of the phenomenology of thinking. However, as we will see in the following sections, the view that attributions of mental agency are purely retrospective judgments assumes an incomplete notion of the phenomenology of thoughts. So here we are left with a dilemma: On the one hand, our thoughts are experienced passively. On the other hand, the passivity of our thoughts does not lead us to doubt if it was really us who generated them (in normal conditions). Even though thoughts are passive from an experiential point of view, it is possible to take an agentive stance towards them and finally reach the belief that one is the author of at least some of the thoughts passively appearing in one’s stream of consciousness. The challenge is to reconcile our intuitions about being the authors of our own thoughts with a passive phenomenology of thoughts. In other words, the issue is to make sense of how we come to self-attribute thoughts in agentive terms even though they do not feel as something we do.
3. Explaining Self-Attributions of Mental Agency
The aforementioned disagreement about the phenomenology of thoughts has led to a conceptual debate about the best way to characterize the architecture of our attributions of mental agency. In this context, two main rival approaches can be distinguished in the current literature, both appealing to different characterizations of the phenomenology of thoughts.
3.1. The Top-Down Formulation
In their seminal work, Graham and Stephens (1994; see also Stephens & Graham, 2000) develop a top-down view that characterizes attributions of mental agency primarily as the product of reflective acknowledgment43. A subject reflectively realizes and is able to report that she is the author of a certain thought because she retrospectively makes sense of its occurrence in agentive terms. The agent of a certain thought arises in explaining the occurrence of that thought44. On this view, such an explanation results from second-order inferences made on the basis of introspective self-observations in light of the occurrence of phenomenally accessible thoughts. Strictly speaking, on this view self-attributions of mental agency are the product of introspective mechanisms. Thus, given that the agent of my phenomenally available thoughts is always an explanation for their occurrence, it is assumed that this agent is not part of the representational content of thought. There would be nothing special about the phenomenal character of thoughts
43 Another popular top-down view about attributions of mental agency can be found in Campbell (1999). For recent top-down versions of this modality of attribution, see Synofzik et al. (2008), and Vosgerau and Voss (2014). 44 In this sense, top-down views can be also called explanationist views.
60 that allow them to be self-attributed in agentive terms. How exactly do people come to retrospectively self-attribute thoughts in terms of agency? Graham and Stephens (1994a) suggest that:
[W]hether I take myself to be the agent of a mental episode depends upon whether I take the occurrence of this episode to be explicable in terms of my underlying intentional states. (Graham & Stephens, 1994a, p. 93)
On the top-down views the stress is put on whether we are reflectively able to makes sense of, or explain, of our phenomenally available thoughts in terms of our background knowledge, beliefs, desires, cultural ideas, etc., retrospectively, so:
[T]he subject’s sense of agency regarding her thoughts likewise depends on her belief that these mental episodes are expressions of her intentional states. That is, whether the subject regards an episode of thinking occurring in her psychological history as something she does, as her mental action, depends on whether she finds its occurrence explicable in terms of her theory or story of her own underlying intentional states (Graham & Stephens 1994a, p. 102; see also Stephens & Graham, 2000, p. 162).
This version of the top-down formulation of attribution of mental agency takes this modality of self-attribution to depend on whether the subject can fit the thought-content in the picture he has of herself. Thus ‘the subject unproblematically accepts a thought as her action if, by her own lights, it accords with her intentional psychology – if roughly, it is the sort of thought [content] she would expect herself to think given her picture of herself’ (Graham & Stephens 1994b, p. 103). This top-down way of thinking about agentive mental self-attributions is based on Dennett’s (1987, 1991) and Flanagan’s (1992) account of self-referential narratives. Commenting on this, Graham & Stephens (1994a) suggest that:
A favoured narrative strategy consists of explaining behavioural episodes, for example, as expression of underlying, relatively persistent intentional states. Such explanations serve to make sense of behaviour retrospectively and also provide the subject with a framework of expectations regarding her future behaviours (p. 101).
It is suggested that the main role of self-referential narratives is to organize the multiplicity of phenomenally available mental states we undergo into a coherent and more or less consistent projectable pattern of thinking. Thus, we make sense of our own thoughts by explaining and integrating them into this narrative pattern.
61 The top-down formulation of self-attributions of mental agency seems consistent with the phenomenological picture of thoughts I have offered. However, as it stands, this view faces some other difficulties. First, it is not clear whether we can really say that we introspectively agentially attribute a certain thought depending on whether the thought-content in question is consistent with the picture one has of oneself. Often I find myself having thoughts I can hardly make sense of as being consistent with the picture I have of myself (e.g. ‘I’m not evil’). On many occasions we find ourselves saying things like ‘I never thought I was capable of thinking something like that!’. However, this does not imply that we do not self-attribute these thoughts in agentive terms: we aer still the author of those thoughts.
Often, the contents of our some of out thoughts strike us surprisingly, having an obscure, illogical, irrational, or even silly nature. This dissociation between agentive mental self- attributions and self-image-consistency is what makes, among other things, the experience of moral conflict intelligible. In these cases, a person S with a certain image of himself IM finds himself thinking a thought T that seems to go against IM. For S to have a moral conflict, S needs to self-attribute T even though T goes against IM. In fact, one might say that, in these cases, this agentive self-attribution is one of the most important conditions for the subjective experience of a moral conflict. It is the agentive self-attribution of these thoughts that colours them with a subjective conflictive nature. So, it is just not true that attributions of mental agency depend on whether thoughts can fit the picture one has of oneself, or at least, not in the way in which this version of the top-down view of self-attribution of mental agency requires. One does not need to be in agreement with the content of a certain thought for one to self-attribute that thought in terms of agency.
A second related problem here is that it seems implausible to claim that we form a projectable pattern of thinking, or at least, that we are aware of such patterns when self- attributing thoughts in agentive terms, as the top-down view in question implies. Perhaps the creation of a projectable pattern of behaviour is true for the bodily case, but it sounds odd in the case of thinking (even if we talk about ‘mental behaviour’). In the latter case, one does not project a certain type of thought-content in certain situations, one just thinks them. Arguably, self-narratives might help us to make sense of phenomenally available thoughts retrospectively but not to project thought-patterns onto future situations.
A third problem for the present formulation of agentive mental attributions is that, even if it is able to explain self-attribution of thoughts (as a retrospective explanation), it is not be able to explain the external attribution that characterizes thought insertion (Gallagher, 2004). Top-down
62 defenders suggest that, given that I cannot make sense of the causal path of a certain thought, the best explanation available is that ‘the thought must be someone’s else’ (Graham & Stephens, 2000). However, the inability to track the causes of a certain thought would only entail that the thought appeared out of the blue, not necessarily that someone else authored the thought. Sometimes, I might be unable to track the causes of certain thoughts; however, this does not imply that I end up externalizing my untraceable thoughts. There seems to be here an additional step that the top-down formulation of attributions of mental agency cannot really explain. Finally, in relation to this last point, a problem with the top-down formulation is that it tends to assume a very poor picture of the phenomenology of thoughts. Our experience of thoughts does not only include thought-contents, it also includes different possibilities of action (Ratcliffe, 2013). It seems that these possibilities given in experience would play an important role in explaining the way we end up self-attributing certain thoughts in agentive terms. Certainly, a plausible explanation for this modality of self-attribution should take this into account. However, this is neglected by the top-down formulation of mental self-attributions, I will address this further in section 5 while sketching my own alternative to the problem.
3.2. The Bottom-Up Formulation
Some authors have formulated the notion of attributions of mental agency in a bottom-up fashion, namely, as a matter of endorsing a certain experiential feature contained in the first-order representational content of thoughts (Gallagher, 2000; 2007; 2012; Zahavi, 2005; Gallagher & Zahavi, 2008)45. Here, a thought is agentially self-attributed because it simply feels as something one is doing. This is not to deny that there are robust judgements of mental agency; rather, it is to claim that ‘higher-order attribution of ownership or agency may depend on the first-order experience of ownership or agency’ (Gallagher, 2007, p. 348). For bottom-up defenders, there would be something special in the phenomenology of agentive thoughts that would make us to self-attribute them in agentive terms. More specifically, there would be a full experience of mental agency (sense of mental agency) associated to the most basic phenomenology of thoughts. Thus, whereas top-down views argue that attributions of mental agency only occur as a result of second-order judgements, bottom-up approaches claim that these second-order attributions reflect an underlying first-order experience of agency, namely, a sense of agency (De Hann & De Bruin, 2010, p. 375). If we track back the causes of certain thoughts, it is because thoughts already feel that have been created by us. Therefore, on bottom-up views, conscious attributions of mental agency are based on pre-reflective representational information of phenomenally available
45 From this point of view, bottom-up views are endorsement views.
63 thought prior to introspection, or, in other words, thoughts would include representational information about their authors (Gallagher; 2007a; 2007b; 2012; 2014)46.
The first and most evident problem with this formulation of attributions of mental agency is that it does not match the passive phenomenology of thoughts. Although it assumes a richer picture of the phenomenology of thoughts, such a picture seems to be mistaken. This formulation requires a full experience of agency figuring in the basic phenomenology of thoughts for us to self-attribute thoughts agentially. In other words, this account requires experiencing thoughts as something one does; it requires the phenomenology of thoughts to be active. However, this is not the case, as I already shown in section 2.3. This basic misunderstanding originates in the argumentative context in which bottom-up accounts of attributions of mental agency have emerged. Often, the treatment of mental agentive attributions arises in the context of bottom-up characterizations of self-attributions of bodily agency (Gallagher, & Zahavi, 2008; Gallagher 2000a, b, p. 204; 2005, p. 173; see De Hann & De Bruin, 2010). Bottom-up formulations of attributions of mental agency are characterized by a lack of a specific and careful treatment of the issue as distinct from the case of bodily agency. On many occasions, authors move freely from the bodily to the mental domain without any type of restriction and, this lack of conceptual and phenomenological constraints seems to be one of the most problematic methodological issues for the bottom-up formulation of attributions of mental agency.
This lack of specificity in the treatment of this issue about mental agency on bottom-up formulation of this modality of self-attribution becomes evident in many places47:
Sense of self-agency: The pre-reflective experience that I am the one who is causing or generating a movement or an action or thought process (Gallagher, 2012, p. 132, my emphasis)
Sense of agency – as I act or think, the pre-reflective experience that I am the cause/initiator of my action or thinking, and have some control over it (Gallagher, 2014, p. 2, my emphasis).
The sense of agency refers to the sense of being the author or source of an action or thought (Zahavi, 2005, p. 143, my emphasis)
46 By pre-reflective I only mean prior to introspection. 47 See, for example, Gallagher (2014) section 1 and 2.
64 Schizophrenics who suffer from these symptoms [delusions of thought insertion and alien control] acknowledge that they are the ones that are moving, that the movements are happening to their own body, or that thoughts are happening in their own stream of consciousness, but they claim that they are not the agents of these movements or thoughts– when in fact they do cause the movement or thought (Gallagher 2007b, p. 36, my emphasis).
Most of the time, bottom-up defenders treat thoughts in the same way they treat motor actions, which seems to be the source of most of the problems for this position. A number of authors associated with the current phenomenological tradition show a tendency to assume the same phenomenological picture in the case of conscious thought as in the case of motor actions, and, based on this, they tend to characterize attributions of mental agency in the same way they explain attributions of bodily agency (Zahavi, 2005; Gallagher, 2000; 2007; 2014; Gallagher & Zahavi, 2008). This is a crucial mistake in the whole characterization of attributions of mental agency. As I have already pointed out, such parallelism overlooks the passive phenomenology of thoughts as radically different from the phenomenology of motor actions. In characterizing attributions of mental agency, bottom-up approaches neglect the fact that bodily actions and thoughts belong to different domains of our mental life and that their phenomenologies are not really comparable. Given the phenomenological passivity of thoughts, bottom-up approaches have serious problems in explaining the type of representational content of thoughts that they require in order for the bottom-up formulation to be true. These authors would need to argue for the existence of first-order thoughts with representational content of the type ‘I am the subject initiating this thought’. However, this type of representational content does not seem to be consistent with the passive phenomenology of thinking that, in contrast, seems to suggest that the author of a thought it is not included in its representational content – at least, not as its agent (Vosgerau & Voss, 2014).
Finally, bottom-up formulations also face an explanatory problem. Even if we accept, for the sake of the discussion, that thoughts are self-attributed on the basis of a first-order sense of agency (active phenomenology), bottom-up views would not be able to explain how unbidden thoughts are also agentially self-attributed if their phenomenology is passive, namely, if no experiential sense of agency is associated with their occurrence. As Gallagher himself (2014) recognizes, ‘a lack of sense of agency is also found in cases of unbidden thoughts’ (p. 4). One might suggest that even though they do not enjoy a sense of agency, we self-attribute unbidden thoughts as a matter of retrospective explanation. However, this kind of explanation would fall into the bottom-up camp, and bottom-up defenders would certainly not want to accept this. As it
65 stands, it seems clear that the bottom-up formulation cannot explain either normal cases of agentive self-attribution (phenomenological problem), or cases of agentive self-attribution of unbidden thoughts (explanatory problem).
4. Attributions of Mental Agency, Psychosis, and Thinking as a Motor Process
The discussion about the nature of attributions of mental agency emerges in trying to account for the type of breakdowns that characterise, among others, delusions of thought insertion. In fact, with time, it became standard to explain this phenomenon in terms of problems with the attributions of mental agency that patients make (Campbell, 1999; 2000; Frith, 1992; Graham & Stephens, 1994; Stephens & Graham, 2000; Gallagher, 2000; 2004)48. In this context, popular explanations for the production of normal and abnormal attributions of mental agency involve the idea that thoughts can be understood as motor processes (Feinberg, 1978; Frith, 1992; Schmahmann, 2007; Ito, 2008). This influential parallelism was pioneered by Hughlings Jackson (in Taylor, 1958), who claims that mental operations such as thoughts exploit the organization of the sensorimotor system. Influenced by Jackson, Feinberg (1978, p. 638) comes to claim that ‘If thought is a motor process heavily dependent upon internal feedback, derangement of such feedback might account for many of the puzzling psychopathological features of the “psychosis of thinking” [aka thought insertion]’. However, even the origin of this parallelism is problematic as Feinberg himself recognizes that he has not independent evidence in favour of this claim. As Proust (2009, p. 257) rightly points out ‘what [Feinberg] was offering was an evolutionary speculation rather than an empirically established claim’. In this section, I make evident the implausibility of this parallelism by focusing on one of its most plausible versions, namely, Campbell’s (1999) model of thinking.
Assuming that thoughts are motor processes, John Campbell (1998; 1999; 2001; 2002) develops a theory of attributions of mental agency based on the comparator model originally developed to explain motor control (Frith, Blackmore & Wolpert, 2000). The idea is that every time a subject thinks a thought P, the subject has previously formed an unconscious intention to think that thought I-P49. After the different mechanisms involved in the production of P brings P into the subject’s stream of consciousness, P and I-P are compared. In the case where P and I-P match, the subject would self-attributes P in terms of agency. However, if they do not match, the
48 The standard approach to thought insertion has been extensively criticised over the last fifteen years (Gallagher, 2000; Bortolotti & Broome, 2009; Proust, 2008; Synofzik, Vosgerau, & Newen, 2008a; Synofzik, Vosgerau, & Newen, 2008b; Vosgerau & Newen, 2007). 49 This is one of the main differences between Campbell and Frith’s (1992) comparator model of thinking. In the latter case, the intention to think is conscious. For a specific critique of Frith’s model, see Gallagher (2000).
66 subject does not have an impression of being the author of the phenomenally available thought, so she does not self-attribute the thought in terms of agency. Campbell’s proposal implies that attributions of subjectivity are always preserved, whereas attributions of mental agency can be disrupted, as, for example, in cases of thought insertion.
This proposal relies on a belief-desire thought-causation framework. A motor command is needed to activate each thought token: ‘the background beliefs and desires cause the motor instruction to be issued’, which ‘causes the occurrent thought’ (Campbell 1999, p. 617). In turn, this would explain ‘how the ongoing stream of occurrent thoughts can be monitored and kept on track’ to finally match the thoughts with their correspondent intentions (p. 617). Although this model is undeniably influential, Campbell’s proposal faces a number of phenomenological, conceptual, explanatory, and methodological problems. In fact, it is far from clear whether the very idea of a comparator system makes any sense in the case of thinking.
The intention to think is a very unclear notion and it does not seem to match the passive phenomenology of normal thought; perhaps the notion can be better understood as the product of a framing retrospective judgment about the occurrence of certain thoughts, but not as a part of the actual experience of thoughts50. In addition to this, Campbell’s model goes against another basic phenomenological observation. The experience of our own normal thoughts is neither accompanied nor followed by any awareness of any type of intentions to think those thoughts. Consequently, there is no such thing as the impression of matching a certain intention to think with the actual thoughts appearing in my stream of consciousness. A final phenomenological worry is that the notion of intention to think would not match the phenomenology of unbidden thoughts (Gallagher, 2000; Synofzik, Vosgeray & Newen, 2008). Unbidden thoughts can be interpreted as thoughts that lack a preceding intention to be thought, yet are self-attributed in terms of agency. As it stands, Campbell’s model cannot make sense of these cases.
Campbell’s model also raises some conceptual worries. For a subject to be able to compare the I-P and the thought P, the I-P and P must have exactly the same content. The only difference between P and I-P in Campbell’s model is that one is unconscious I-P and the other is not P (Campbell, 1999). However, this would make the ability to keep track of thoughts impossible, as the intentions to think my own thoughts would not be available to conscious scrutiny. In fact, if I-P is not consciously available, the ability to compare P and I-P itself is
50 By this, I mean that subjects might have the ability to create the impression of having had certain intentions to think when integrating potential causal contextual information about the occurrence of certain thoughts. However, this does not mean that those intentions are given in the experience of thoughts. In a certain way, those intentions would be illusionary.
67 undermined; in this sense, Campbell’s model is self-defeating. Now, if intentions to think are unconscious thoughts, and thoughts themselves are motor processes, for every intention there must be another preceding intention to generate it. In this sense, Campbell’s view leads to an infinite regress. As Synofzik, Vosgerau and Newen (2008a, p. 235) rightly conclude, here we are left with a dilemma: ‘either intentions are thoughts and we face an infinite regress, or intentions are unconscious and then conscious thinking is a mere epiphenomenon such that the comparator and the SoA [sense of agency] could not have any function at all’ (Synofzik, Vosgerau & Newen, 2008a, p. 235).
When trying to deal with cases of thought insertion, Campbell’s model faces an explanatory problem. Even if the model could make sense of cases of agentive mental self- attribution in normal cases, it is not able to explain the external attribution that occurs in cases of thought insertion. The mismatch between P and I-P would only explain the fact that a certain thought is not given as authored by me because I-P cannot contain representational information about an external agent (Vosgeray & Voss, 2014, p. 543). In these cases, a thought might be only experienced as appearing out of the blue. However, not all my out-of-the-blue thoughts are attributed to external agents as it is shown by unbidden thoughts. Thus, Campbell’s explanation of thought insertion collapses into the explanation of unbidden thoughts, and this is certainly a serious explanatory problem for the view. Perhaps, a plausible way to avoid this worry might be to introduce a second-factor explanatory disturbance. Thus, a mismatch between an intention to think and the actual thought would not be sufficient for a person to externally attribute a thought. In addition to this disturbance, a second disturbance in the way subjects explain their own thoughts – not present in cases of unbidden thought – would be required. Thus, the interaction between these two factors would explain the implausible type of mental attribution that is made by thought insertion patients. However, this suggestion goes beyond Campbell’s model, so the explanatory problems stands.
Finally, there is a methodological problem that seems to apply to all versions of the comparator model for the case of thoughts. Most of the evidence for different neuropsychological impairments leading up to the disruptions in the attributions of mental agency underlying thought insertion has been established by analogy with the evidence for existing impairments in cases of alien control of movements. The problem with this move is that – as Synofzik et al. (2008) rightly claim – unlike bodily movements, thoughts do not have the sensorimotor characteristics to inform a feed-forward inhibition of the self-monitoring system, which is the subpersonal mechanism that is claimed to be defective in cases of delusions of alien control (Frith, 1999;
68 Campbell, 1999). First, it is not clear that the impairments identified in these cases actually lead to the delusions of thought insertion. Second, and more important, is that the case for impairments in any type of comparator model related to conscious thought has not been made based on direct evidence (perhaps, because there is no such thing as a comparator model for thoughts). In conclusion, pace Campbell’s model, it does not seem plausible that we can use any model that strongly relies on the sensorial nature of bodily actions to explain how we self- attribute agency to our thoughts. Such a move leads to the aforementioned phenomenological, conceptual, explanatory, and methodological problems. It sounds reasonable to suggest, in turn, that models that do not rely on this parallelism might be in a better place to explain how we come to externally and self-attribute our phenomenally available thoughts.
5. Affording Mental Agency: A Proposal
In light of the many disagreements surrounding the current discussion about our attributions of mental agency, a search for new alternatives seems more than justified. In this section, I explore one potential alternative that considers the notion of affordance as a key element in the challenge of understanding this phenomenon. The most fundamental issue at hand in this context is the clarification of the phenomenology of thoughts in light of the question about agency; only by clarifying this issue we can produce correct formulations of the way in which we self-attribute thoughts in agentive terms. As I have already argued, the phenomenology of thoughts is fundamentally passive i.e. it does not involve any type of full first-order feeling of mental agency. Thus, the bottom-up view struggles to explain the target phenomenon of this paper; however, this does not imply that the top-down view is correct either. The passivity of our thoughts is just half of the story, and the top-down view seems to ignore the second half when assuming a very poor notion of the phenomenology of thoughts. Here, I maintain that any accurate and complete phenomenological exploration should include the notion of affordances, and the case of thoughts is no exception.
The term affordance refers to a set of potential actions that the awareness of certain experiential states invites. Although the notion is introduced by Gibson (1979), the concept of affordance seems to be rooted in Husserl’s philosophical work on the phenomenological role of possibilities (1973; 1989, see also Merleau-Ponty, 1962). Husserl observes that when seeing a certain entity, let’s say a cup of tea, we do not only experience what actually appears to us at the time, i.e. the cup. In addition, the cup appears as something I can grasp; it appears as graspable. The cup appears as engageable, so to speak, in a number of different ways. To put still another way, my awareness of the cup invites different actions based on a subject’s abilities and
69 expectations. Husserl calls all the possibilities that the awareness of an entity invites, the entity’s horizon.
Now, consider what McClelland (2015) suggests based on Gibson’s idea of affordances:
When playing football, the ball is not just experientially given as red and round; it is also given as kickable. We do not only perceive a cup of tea as white, but also as reachable. We don’t just perceive Justin Bieber’s face as babyish and self-satisfied, we perceive it as slappable (p. 16).
The key unifying idea behind Husserl’s and Gibson’s proposals seems to be that the awareness of our perceptual states incorporate practical possibilities in the form of potential bodily acts and other potential happenings, and that the opportunity to perform these acts figures in the phenomenology of these states (Ratcliffe, 2013, p. 237). As McClelland (2015) rightly points out, ‘there is a manifest phenomenological difference between just seeing the ball and seeing it as kickable’ (p. 16). Thus, the phenomenology of all our perceptual experiences is coloured by different affordances 51. Originally, Gibson (1979) claims that to perceive an affordance – as the opportunity to perform a certain bodily action for example – is to stand in a non-representational ‘picking up’ relation to it. However, here I follow Prosser (2011), Siegel (2014) and McClelland (2015) and take experiences to be fundamentally representational, so an affordance would contribute to our phenomenology only in cases where a certain experiential state represents the presence of that affordance52.
I believe that, in the same way we can talk about affordances in the case of perceptual experiences, so it is plausible to talk about affordances in the case of awareness of cognitive experiences. In this sense, thoughts would also be coloured by different cognitive affordances, our awareness of them inviting different mental actions. This proposal is rooted in the work of people like Scarantino (2003, p. 960), Ratcliffe (2013) and McClelland (2015, p. 18). The idea is that, just like the awareness of a bright light or a loud noise affords attention under certain circumstances, so the awareness of a certain thought affords a number of different mental acts, such as attending, contemplating, concentrating, and so on, depending on the circumstances and capacities of a subject. From this point of view, it is not implausible to talk about cognitive experiences after all.
51 Husserl himself does not use the term ‘affordance’, but his notion of an entity’s horizon makes plausible a parallelism. See Zhok (2013). 52 I shall make this assumption given that the best way to characterize the notion of affordance is still under debate (Scarantino 2003, p. 949; Jenkins 2008, p. 43).
70 Here one might propose an objection to the idea of cognitive affordance. It can be suggested that physical objects are represented as affording certain actions in virtue of their being represented as possessing certain intrinsic features. Something is grabbable because of its shape, reachable because of its location, and so on. Therefore, it might be suggested that it is not at all clear how this general picture is supposed to work for the case of thoughts. There is a simple reply to this objection. It's true that the intrinsic properties of objects play a key role in mainstream affordances, but relational properties do too (e.g. the distance of the object from your hand). Here I suggest that there is no reason why affordances have to involve perception of intrinsic properties. In this sense, it is important to note that cognitive affordances are not like physical affordances in all respects, and this would be just one of many differences between them. The critic might insist that affordances must involve bodily actions, so cognitive affordances are no affordances at all. Again, this reply fails to recognize the different nature of cognitive affordances compared with physical affordances, which is a merely terminological dispute. The main issue is that if one’s capacities to introspect, attend, attribute, concentrate and so on can pervade the phenomenological quality of the awareness of one’s thoughts, then cognitive affordance are affordances in every way that matters to our discussion.
Taking all these ideas into consideration, I suggest that, although thoughts are fundamentally passive, at the same time, our awareness of them is characterised by the presence of an affordance of agentive attributability. Here it is crucial to distinguish phenomenal awareness of a thought from the act of attributing agency to those phenomenally available thoughts. Agentive self-attribution and external-attribution would be potential actions that thoughts afford depending on different external factors and the subject’s capacities. Although thoughts are passive, we experience the potential to self-attribute them and this possibility pervades our awareness of them.
The experience of this cognitive affordance can vary depending upon a number of factors: background knowledge, traits of personality, affective states, surrounding perceptual conditions, cultural beliefs, among many others. In this sense, the awareness of our thoughts can be said to be cognitively penetrated by all these factors. Consider the hypothetical case of a non- western culture where there is no belief that ‘one is the author of one’s own thoughts’; here, an affordance of self-attributability would not be identified in the normal phenomenology of thoughts of a member of this culture, so in this sense, this cognitive affordance might be taken as instantiating certain cultural expectations53. Perhaps this non-western culture might have the
53 I thank Prof Tim Bayne for this suggestion. In fact, I think that the same can be said in cases of bodily affordances.
71 belief that thoughts are divine gifts, so an affordance of external-attributability would pervade the phenomenology of their own normal thoughts54.
The influence of all these factors in the awareness of our thoughts might explain, for example, the variability in the way people report their own thoughts discussed in section 2.3 (even within the same culture). At the same time, all these factors would influence how quickly persons go on to endorse a certain cognitive affordance and perform the potential act it invites. Of course, this endorsement is also influenced by the practical context in which a certain thought emerges. This might then explain the difference between unbidden thoughts and those thoughts that emerge, for example, in trying to solve a logical puzzle. Both types of thoughts are usually self-attributed in terms of agency, but the quickness with which this act is performed varies, I suggest, given the context in which they appear. While in the former case the subject is not expecting the unbidden thought to appear in her stream of consciousness, in the latter the subject is trying to find an answer. This difference would allow a quicker agentive self-attribution in the latter case even though the awareness of both types of thought involves an affordance of self- attributability.
Affordances of mental attributability need to be distinguished from the final act of attributing a certain thought to oneself in agentive terms. As mentioned before, the former does not entail performing the latter. Strictly speaking, the affordance model I defend here claims that the act of agentive self-attribution can be understood as an explanation of the occurrence of phenomenally available thoughts. It denies the existence of a full bottom-up sense of agency accompanying unreflected thoughts from which higher-order explanations are informed. Some would say that his amounts to a top-down view; however, unlike current top-down views, the present view also maintains that this agentive type of explanation is informed by the endorsement of an element that figures in the awareness of thoughts, i.e. the affordance of mental attributability. While denying a full sense of mental agency, the affordance model also claims that there is something in the phenomenology of thoughts that informs agentive explanations, which is an idea that reflects something of the spirit of bottom-up formulations.
Once the affordance of attributability is endorsed, subjects would go on to explain the occurrence of the thought by making sense of it in light of their many potential causal factors.
54 Cognitive affordances should be distinguished from the act of making judgements about cognitive experiences. Believing that I can self-attribute phenomenally available thoughts (leading up to a top-down attribution type) is certainly different from experiencing a thought as self-attributable. Merely identifying the belief of a subject fails to capture how this attributability figures in her phenomenology.
72 Thoughts can be produced by a number of internal and external factors (Martin & Pacherie, 2013)55. In explaining thoughts, subjects would integrate these factors with the occurrence of the actual thought retrospectively, leading to the production of explanations in terms of agency that are well-grounded in causal information. This process of coherent and integrative agentive explanation would create a retrospective picture of the causal path of occurring thoughts leading to a certain experience of mental agency (always derived from the already structured agentive explanation). From this point of view, the experience of being the author of one’s thoughts is the final product of this process of retrospective explanation, not an element contained in the basic phenomenology of thoughts, as bottom-up advocates propose. Agentive explanations require our awareness of thoughts to be embedded in a certain cultural, perceptual and psychological framework. From this point of view, the specific author of an unreflected thought is not part of its representational content; rather, the agent of a thought is retrospectively afforded in the act of explaining its occurrence. In this sense, agentive explanations would constitute an integration between a subject’s background psychology (knowledge, beliefs, affects, traits of personality, and so on) with contextual information related to the conscious occurrence of a thought.
As it might be anticipated, attributions of mental agency within this affordance model would strongly depend on introspection. I take introspection simply as the registering of our own mental states. In this sense, introspection would go beyond merely attending thoughts, as it implies an examination of the many features of our own thoughts, including an appreciation of the way in which one becomes aware of them. Experiencing a thought in my stream of consciousness is quite different from attributing self or external agency to it. Since unreflected thoughts do not include a full sense of agency, but they do include an affordance of self- attributability, the act of self-attribution would be performed in introspecting phenomenally available thoughts. Allegedly, we can expect people who have problems introspecting to have problems in the act of making sense of the causal path of their own thoughts (see Vosgerau & Voss, 2014). However, further research is needed in order to support this claim.
6. Implications of the Affordance Model of Mental Agency: Explaining External Attribution
Up to now, most of the development of my proposal has been focused on the explanation of self-attributions of agency. In this section I shall sketch a possible way of understanding the external attribution of agency that characterizes the phenomenon of thought insertion. As I have claimed, any plausible account of the nature of attributions of mental agency should be able to
55 For a further treatment of this issue, see paper 3 of this compilation.
73 make sense of this psychopathological issue, and this is exactly where some of the most popular models of attributions of mental agency fail. Here, the task is twofold. First, the affordance model needs to account for how an affordance of external attributability might figure as a possibility in the awareness of certain thoughts. Second, given that the presence of an affordance does not necessarily entail the act it invites, an affordance model needs also to explain why thought insertion patients endorse such a bizarre possibility leading to the final external attribution characteristic of the phenomenon.
As has been suggested, our experience of cognitive affordances might vary depending upon psychological, affective, perceptual and even cultural conditions. In addition, this awareness would also vary depending upon the other accompanying phenomenal features of thoughts. The most basic subjective structure of inserted thoughts can be divided into a negative and a positive aspect56. The negative aspect refers to the fact that patients report certain abnormal thoughts lacking a sense of ownership. The positive aspect refers to the external attribution that patients make based on the phenomenal feature of the abnormal thought allegedly present in their stream of consciousness (Synofzik, Newen & Vosgerau, 2008a; Martin & Pacherie, 2013). These two aspects can be observed in following report:
I didn’t hear these words as literal sounds, as through the houses were talking and I were hearing them; instead, the words just came into my head –they were ideas I was having. Yet I instinctively knew they were not my ideas. They belonged to the houses, and the houses had put them in my head (my emphasis, Saks, 2007, p. 29).
The first element to consider is that, in these cases, certain individual thoughts enjoy an abnormal phenomenology. Patients do not feel these thoughts as their own thoughts (Mellor, 1960; Fish, 1962; Frith, 1992). As Spence et al. (1997) comment ‘one man said that thoughts were being put into his mind and that they “felt different’ from his own”. In this sense, an attribution of mental ownership would not be preserved in these cases because no sense of ownership is identified by the patients (Metzinger, 2003). In addition, it has been also suggested that apart from this lack of ownership, these patients experience the relevant thoughts as inserted (Billon, 2013; Billon & Kriegel, 2015). The feature of being inserted would not be part of an explanation offered for the occurrence of thoughts with bizarre phenomenal features. Rather, it would figure in their primary phenomenology. The second issue to be considered is that delusions of thought insertion do not emerge out of the blue. They arise in the context of a
56 For a more specific treatment of this issue, see the introduction to this compilation (Section 3.1.).
74 number of affective and perceptual changes (Fuchs, 2005; Ratcliffe, 2013; Marhawa et al. 2013)57:
The environment obtains a strange, artificial and puzzling character. It seems arranged like a stage setting and things give the impression of being only covers or imitations for an undeterminable purpose. But in the midst of this overall estrangement, a second change occurs: single objects gain a new, mysterious and bewildering expression or meaning. The sight of a limping man on the street may suddenly evoke the impression of the devil hunting the patient (Fuchs, 2005, p. 134).
Taking all these phenomenal changes into consideration, it seems plausible to claim that certain thoughts might include an affordance of external attributability. If a thought feels inserted, it is quite natural to suggest that an affordance of external agentive attributability might pervade the awareness of those thought. Of course, this suggestion is based on the view that the author of a thought is not an intrinsic part of its representational content (see sections 2.4. and 5). Perhaps this abnormal type of affordance is given simultaneously with a normal affordance of agentive self-attributability, and this is in fact what explains the conflict, variable degrees of certainty, and ambivalence with which the delusion is sometimes reported (Parnas, 2003; De Hann & De Bruin, 2010)58. As a patient claims ‘thoughts are put into my mind like “Kill God”. It’s just like my mind working, but it isn’t. They come from this chap, Chris. They are his thoughts’ (Frith, 1992, p.66, my emphasis).
Now, the emergence of an affordance of external agentive attributability does not explain its endorsement, so there is a second issue still in need of explanation. Two issues are relevant to solving this. First, as already proposed, delusions of thought insertion usually arise in the midst of affective and perceptual transformation. During this period, feelings of oppression, fragmentation, passivity, uncertainty, lack of control and practical disengagement pervade the patients’ world and self-awareness. Second, psychotic patients present a number of cognitive deficits that might be associated with the way they come to explain abnormal experiences (Coltheart, Langdon & McKay, 2011; Coltheart, 2002; 2015). Before adopting delusional beliefs,
57 As proposed in paper 2 of this compilation, a potential objection here is to claim that not all delusions of thought insertion are adopted in the context of these more general alterations in consciousness. However, thought insertion is taken to be a psychotic delusion by excellence and from this point of view, it is important to note that most psychotic patients adopt delusions in the context of an importantly fragmented experience of themselves and the world (Silverstein & Uhlhaas, 2004; Uhlhaas & Silverstein, 2005). In addition, first-personal accounts of the context in which thought insertion emerge seem to support this idea (Saks, 2007; Payne, 2014). To deny this is to overlook one of the most crucial aspects of the occurrence of most psychotic delusions. In fact, Jaspers (1963) considers this altered phenomenological context in which delusions are adopted as the hallmark of psychotic delusions (see also Sass, 1994, Chapter 3 and Ratcliffe, 2013). For a further analysis of this issue, see 3 and 5 of this compilation. 58 For a further discussion of this issue, see paper 2 of this compilation.
75 patients experience an increased need for closure, i.e. the ‘the desire for a definite answer on some topic, any answer compared to confusion and ambiguity [will do]’ (Kruglanski, 1989, p. 14). Mckay, Langdon and Coltheart (2007) have shown that delusion-prone subjects score considerably higher than healthy controls on the Kruglanski, Webster and Klem’s need for closure scale. Thus, during the period preceding the adoption of delusional beliefs, patients feel a higher need to resolve the all-pervading feeling of uncertainty and unpredictability of the world by clinging to anything that can make sense of the general state of phenomenological confusion and uncertainty they are undergoing. In addition, psychotic patients tend to exhibit an explanatory bias referred to as ‘jumping to conclusions’ (JTC) (see Bortolotti 2010). JTC is related to a deficit in the evaluation of evidence that might support a certain doxastic hypothesis, e.g. that Chris is inserting these weird thought into my mind (see Evans, Averbeck & Furl, 2015). Taking these elements into consideration, the endorsement of an affordance of external agentive attributability leading up to the external attribution that characterizes thought insertion might be prompted by the interaction between these cognitive deficits and the role that such an explanation might play in gaining a certain degree of phenomenal unity and organization in the patients’ experience of themselves and the world (see Mishara & Corlett, 2006)59. Finally, by offering these clarifications, the affordance model I have defended here seems able to make sense of external and self-attributions of agency of thought.
7. Concluding Remarks
In this paper I have offered an alternative explanatory model of agentive attributions of mental agency. In doing so, I have offered an exclusive treatment of agency in the specific context of conscious thoughts without establishing parallelisms with cases of bodily agency and motor control. By appealing to a concept originally pioneered within the discussion about the phenomenology of perceptual states, I have suggested that although unreflected thoughts are fundamentally passive, our awareness of them is characterised by an affordance of agentive attributability. Although thoughts are phenomenologically passive, they also invite certain mental acts. Thus, this affordance model is able to make sense of the dilemma about how we come to self-attribute thoughts in terms of agency even though thoughts do not feel as something we do. At the same, this model is also able to explain how affordances of mental attributability might change within psychotic contexts leading up to the type of external attributions of agency that characterize delusions of thought insertion.
59 For a full defence of this view, see paper 5 of this compilation.
76 I hope to have shown that, given their phenomenological and conceptual weaknesses, current models aimed at explaining external and self-attributions of mental agency are unsatisfactory, and that my proposal is better placed to explain our target phenomenon. One of the main advantages of the affordance model is that it does not establish any type of parallelism between motor actions and thoughts so it overcomes all the problems associated with this implausible move. In addition, this model does not appeal to the existence of intentions to think involved in the generation of attributions of mental agency, one of the most problematic issues within Frith’s and Campbell’s models of conscious thinking. The analysis offered here has taken seriously the intuitions driving both current bottom-up and top-down formulations of the agentive modality of mental self-attribution, finding that both formulations are partly right and partly wrong. While current bottom-up views assume a rich but mistaken picture of the phenomenology of thoughts, current top-down formulations endorse a correct but incomplete view of this issue. The dialectical significance of my model is that it finds a middle ground between bottom-up and top-down positions, integrating their most plausible elements. Thus, it seems that the integration of the concept of affordances into our target discussion might not only help to get a better grasp of the architecture of attributions of mental agency, but also to clarify the foundational issue about how to best characterize the phenomenology of thoughts in terms of agency. In conclusion, by adopting an integrative stance, the affordance model of agentive mental attributions might be able to gain better dialectal traction than either of the two entrenched positions established in the current literature.
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81 Thought Insertion as Hybrid Delusional Beliefs
Summary
Some of the most dominant current approaches characterize delusions as abnormal beliefs rooted in anomalous experiences of different kinds. Nonetheless, the exact role of these experiential abnormalities in determining the content of delusional beliefs is still under debate within these approaches. Two alternatives can be identified on this issue. On the one hand, endorsement models claim that the abnormal experiences comprise the very content of delusional beliefs so patients simply endorse what they have experienced. On the other hand, explanationist approaches claim that delusional beliefs emerge as explanations for abnormal experiences with less specific content. The purpose of this paper is to evaluate the main arguments for and against these views in the context of the occurrence of delusions of thought insertion. After concluding that both alternatives can partially resist some of their main objections, I claim that in order to solve the dispute we should look closer at the structure of normal beliefs and take an integrative stance towards the problem. Thus, I propose that single delusional beliefs of thought insertion have various propositional contents and that patients might arrive at some of them via endorsement and at some others via explanation. In consequence, we should characterize thought insertion as hybrid delusional beliefs. Finally, I explore potential formulations of this hybrid model maintaining that the endorsement-explanation relationship in the formation of delusions of thought insertion depends on, inter alia, the phenomenal nature of the thoughts of which patients are aware, surrounding perceptual conditions, and the subject’s own psychological architecture.
Acknowledges: I would like to thank Prof Dr Thomas Fuchs and Dr Rob Knowles for useful comments on earlier drafts of this article. Special thanks go to Roberta Payne whose comments from a first-personal point of view of schizophrenia were fundamental to develop some of the ideas contained in this work.
82 O! who can hold a fire in his hand By thinking on the frosty Caucasus? Or cloy the hungry edge of appetite By bare imagination of a feast? Or wallow naked in December snow By thinking on fantastic summer’s heat?
William Shakespeare (Richard II, Act I, scene iii)
1. Introduction
Thought insertion is a bizarre monothematic delusion usually regarded as a key – but not exclusive – symptom of psychotic disorders such as schizophrenia (Schneider, 1959). Patients report being aware of certain thoughts that have been placed into their minds by external agents (Mellor, 1970; Mullins & Spence, 2003). Although the paradigmatic structure of the symptom is more or less clear, the external agents mentioned by the patients are far from belonging to a heterogeneous class; sometimes, patients refer to human beings (e.g. TV celebrities, close relatives, etc.; see Frith, 1992), electronic devices (e.g. TVs, radios; see Spence et al. 1997), collective groups (e.g. aliens, the government, secret societies; see Payne, 2013), or surrounding inanimate entities (e.g. houses, trees; see Saks, 2007), among many others.
In investigating this phenomenon, here I shall assume a doxastic view of delusions i.e. that delusions are an abnormal type of beliefs (Bayne & Pacherie, 2005; Bortolotti, 2010). I also maintain that there may be an important experiential component in the formation of many delusions, thought insertion among them (Jaspers, 1963; Davies et al. 2001). Taking the doxastic account to delusions as their main conceptual framework, current dominant neurocognitive approaches to the aetiology of delusions claim that the mechanisms responsible for the formation of beliefs are also responsible for the formation of delusions under altered conditions (Davies et al. 2001; Coltheart, 2002; 2015). However, there is an ongoing controversy about the way in which the content of these grounding experiential abnormalities determine the final specific content of the delusional beliefs reported by patients (Hohwy & Rosenberg, 2005; Pacherie, Green & Bayne, 2006; Connors, Langdon, Coltheart, 2014; Sollberger, 2014).
In this context, two general alternatives are identified. On the one hand, advocates of an endorsement view suggest that the representational content of the abnormal experience comprises the entire content of the delusional belief so delusional patients would be simply endorsing the content of what they have experienced. When a patient reports the delusional belief with the content
83 bodily movements are being controlled by aliens. In contrast, advocates of an explanationist view suggest that there is a wider inferential distance between the representational content of the abnormal experience and the content of the belief finally held by patients. On this view, patients would form delusional beliefs as a way of explaining highly abnormal experiences with poorer representational content (Davies, Coltheart, Langdon & Breen, 2001). The idea is that the delusional belief with the content
The main purpose of this paper is to evaluate the main arguments for and against these two doxastic views in the context of the formation of delusions of thought insertion. The specific challenge here is to clarify whether thought insertion patients do actually have the experience of a thought as being inserted by the specific agent they identify from which they go on to form the respective delusional belief (Endorsement alternative; Sollberger, 2014); or whether the delusional belief arises as a way of making sense of cognitive experiences with abnormal phenomenal features and poorer representational content (Explanationist alternative; see for example, Synofnik, Vosgerau & Newen, 2008; Parrot, 2012; Vosgerau & Voss, 2014). Thus, after motivating some reasons to endorse a doxastic approach to delusions and developing the main analysis, I conclude that both alternatives can partially resist the objections posited by their critics. After, I claim that in order to solve this dispute we should look closer at the structure of normal beliefs and take an integrative stance towards the formation of our target phenomenon characterizing it as a hybrid doxastic state. The idea is that single delusional beliefs of thought insertion have various propositional contents and that patients arrive at some of them via endorsement and at some others via explanation. Finally, I explore potential formulations of this hybrid model maintaining that the endorsement-explanation relationship in the formation of
84 delusions of thought insertion depends on, inter alia, the phenomenal nature of the thoughts of which patients are aware, surrounding perceptual conditions, and the subject’s own psychological architecture.
2. Understanding Madness: Doxasticism about Delusions
Before engaging with the specific debate about the formation of delusions, we need to engage with a more general philosophical concern about the type of mental state that grounds delusional reports. Let’s call this the typology debate. The answer to this debate would certainly help to clarify methodological choices in research on the aetiology of delusions: if delusions are cases of imaginings, in order to understand delusions we should have a close look at the mechanisms whereby human beings produce their imaginings and what happens when they break down; if delusions are beliefs, one should have a look at the processes whereby human beings produce their beliefs, and so on.
Although it has practical and philosophical relevance, the typology debate is far from resolved and multiple alternatives can be distinguished in current literature. It has been claimed that delusions are cognitive imaginings i.e. imaginative states that are misidentified by the subjects as beliefs (Currie, 2000; Currie & Jureidini, 2001)60. Others – more pessimistically – claim that delusions are empty speech acts with no intentional import (Berrios, 1991)61. Despite appearances, on this view delusions would not be contentful mental states at all62. A more flexible alternative is suggested by Egan (2009) who concluded that delusions are bimaginations, i.e. states with some belief-like and imagination-like features. Finally, sharing Egan’s conceptual flexibility, Schwitzbegel (2012) claims that delusions are neither beliefs nor non-beliefs, but rather, they are in-between beliefs.
Although all these alternatives have their own conceptual and empirical merits, here I assume that delusions are an abnormal type of belief (Bayne & Pacherie, 2005; Bortolotti, 2010; Bayne, 2010). Advocates of the doxastic approach identify some prima facie reasons to believe that delusions are beliefs: The first two reasons are that (i) patients suffering from delusions sincerely assert the content of their delusions and that (ii) the way in which delusions are usually reported by patients seem refer to a belief-type of mental state (Bortolotti & Miyazono, 2014).
60 For a complete assessment of this approach, see: Bayne & Pacherie (2005). 61 Gerrans (2001) calls this position ‘expressivism’. 62 Some authors tend to attribute this view to Jaspers (1963). However, it is not clear that the he did endorse such view, at least not entirely. Jaspers (1963) certainly claimed that some aspects of delusions were incomprehensible, however, he did not claim that delusions as a whole were not comprehensible. For a further analysis on this issue, see: Ratcliffe (2013).
85 When Bisiach & Geminiani (1991) asked a patient with anosognosia if she really believed that her left hand did not belong to her, the patient replied: ‘Yes, I do believe it’. Although first- person reports are not infallible, this seems to give a prima facie reason to claim that delusions are beliefs. The fact of a subject S sincerely asserting that P offers a prima facie reason for doxasticism because such assertion suggests that S believes that P. In contrast, this subjective certainty does not seem to be a feature of others candidates such as imaginings, for example63. Nonetheless, it is important to note that some patients report their delusions with a highly variable degree of certainty. Sometimes, patients refer to the content of their delusions ‘as if’ they were the case (De Hann & De Bruin, 2010).
However, one might say that what these cases show is not that patients are not holding a belief, but rather, that humans can hold beliefs with variable degrees of subjective certainty. In this sense, my doubts about God’s existence do not show that I do not believe in God, but rather, that I have a certain belief and some reasons to doubt it. For many beliefs, it seems uncontroversial to say that one can have them while nurturing doubts about them. In that case, such doubts are just the product of the exercise of my rational abilities. Another option is to say that it is possible to have contradictory beliefs (which is quite different from holding a single belief with contradictory content of the type
. According to Davidson (1982), a subject can have two mutually contradictory beliefs, as long he does not believe their conjunction at the same time i.e.
. The main issue is that subjective certainty should be understood as a matter of degree, so although the degree of certainty in asserting the content of certain delusions can vary, the degree of certainty is not compatible with that of imaginings, for example, where subjective certainty seems low or even non-existent. The truth is that, in most cases, delusional patients assert the content of their delusions with high degrees of subjective certainty at different stages of their aetiological development and this seems to count as a prima facie reason to believe that delusions are beliefs.
A third reason to conceptualize delusions as beliefs is to claim that doxasticism offers a plausible account of the pathological nature of delusions. As Bortolotti & Miyazono (2014) claim:
LA-O’s mental condition [anosognosia] is pathological partly because she seriously denies that her left hand belongs to her. If she did not believe it, but merely imagined it, there would not be anything particularly pathological about her condition, as acts of imagination do not necessarily reflect how things are for the person engaging in the imagining. It is a
63 It is even less clear if this property is a feature of states such as ‘bimaginations’ or ‘in-between-beliefs’.
86 strange thing for LA-O to imagine that her left hand does not belong to her, but we can easily entertain various kinds of strange possibilities in our imagination without losing mental health (p. 32).
A final reason to believe in doxasticism it is to claim that this view offers a phenomenologically and conceptually sound way to make sense of the differences between delusions and other psychopathological phenomena. It is claimed by advocates of the doxastic view that while delusions involve malfunctions somewhere in the processes responsible for normal belief formation, hallucinations would involve malfunctions in perceptual processes (Langdon & Bayne, 2010, p. 322; Coltheart, Langdon & McKay, 2011). In addition, conceptualizing delusions as beliefs would help us to make sense of the distinction between delusional phenomena and some linguistic disorders such as jargon aphasia. People suffering from this condition make strange utterances due to linguistic impairments. Contrasting, a patient asserting that ‘there is a thought in my mind that is not mine’ would do so not because of linguistic impairments but rather because she really believes that something strange is the case.
Despite of all these reasons, a few objections have been put forward against the doxastic alternative. The main argument is what Bayne (2010) calls the ‘functional role objection’ and Bortolotti & Miyazono (2014) call the ‘the argument from causal role’. The idea behind this objection is that delusions would fail to play the paradigmatic roles of regular beliefs (negative claim). This conceptual difficulty might be overcome if delusions were characterized as belonging to a different category of mental state (positive claim). However, the mere fact that delusions sometimes fail to instantiate the paradigmatic features of normal beliefs does not imply that they are not genuine beliefs at all, any more ‘than the fact that a kiwi isn’t a stereotypical bird implies that isn’t a bird’ (Bayne & Hattiangadi, 2013, p. 126). This line of argumentation might only explain the fact that delusions can fail to play the paradigmatic functional role of delusions if they were paradigmatic beliefs. However, it would fail to account for the fact that, most of the time, delusions do display the characteristic features of beliefs. For example, it is claimed that delusions do not guide action like beliefs do. Nonetheless, there are many cases where one can observe how delusional patients do act on their beliefs. For example, a patient reporting the belief that he had two heads (‘perceptual delusional bicephaly’) was hospitalized after attempting to violently remove the second head with a gun (Ames, 1984). It is highly dubitable to say that this patient’s delusion was not playing a causal role in the patient’s thinking
87 and acting64. Certainly, the action of ‘shooting the second head’ seems to be clearly grounded in the belief , which, in turn, was based on the main delusional belief .65 As Reimer (2010) rightly points out:
The mere anomaly of psychiatric delusions, qua beliefs, is little reason to suppose that such delusions are not genuine beliefs. If something is unusual for an x, even highly unusual for an x, we cannot conclude without further argument that it is not an x (p. 324).
Bortolotti (2013) suggests that the main arguments against the doxastic view rely on an over-idealized view of normal beliefs, imposing constraints that not even paradigmatic beliefs would meet. The truth is that delusions do play a belief-role in explaining and predicting certain intentional actions in psychotic patients and, therefore, they might be taken as beliefs, but not of the same kind as normal beliefs (Burgess, Baxter, Rose & Alderman, 1996). Nonetheless, the purpose of this section is not to offer an extensive defence of the doxastic approach to delusions, but rather, just to motivate two ideas: (i) that this view offers a conceptually and phenomenological appealing way to approach the typology debate and that (ii) the doxastic approach is able to open a number of empirically attractive doors to access to the aetiology debate through the discussion of the many faulty mechanisms of belief-formation that would be at the basis of the production of delusional phenomena (Coltheart, 2002)66.
3. Bottom-up Experiential Loading and the Conscious Experience of Thought Insertion
The doxastic approach has become one of the main conceptual frameworks for the development of neurocognitive models of delusional phenomena (Campbell, 1999; Davies et al. 2001; Coltheart, 2002; 2015; Martin & Pacherie, 2013). A popular formulation of this view involves the claim that ‘the proximal cause of the delusional belief is a certain highly unusual experience (Bayne & Pacherie, 2004, p. 2; se also, Davies et al. 2001; Coltheart, 2002; 2015). This is the so-called bottom-up approach67. Bottom-up defenders take the causal relationship between experience and belief as going from the former to the latter. Although everyone on this view agrees on this basic issue, authors disagree on the specific role that these grounding
64 Young & Leafther (1996) conducted a study that showed that all Cotard patients showed some form of delusion- related behaviour and Blount (1986) reports a case of a patient suffering from Capgras delusion that decapitated his stepfather trying to find batteries into his head. 65 In fact, Ames (1984) reports that the patient had initially planned to attack the second head with an axe. 66 Defences of this approach can be found in Bayne & Pacherie (2005), Bortolotti (2010); Bayne (2010); Bayne & Hattiangadi (2013), and Bortolotti & Miyazono (2014). 67 Contrasting with bottom-up approaches, top-down views take delusional beliefs to be Wittgensteinian framework propositions. The claim is that top-down disturbances in fundamental beliefs of subjects would infuse their conscious experiences and actions with an abnormal character. In this sense, delusional experiences could not have their contents without top-down loading (Campbell, 2001, p. 96).
88 experiences have in determining the content of the actual delusional belief finally reported by deluded patients (Hohwy & Rosenberg, 2005; Pacherie, Green & Bayne, 2006; Coltheart, Mckay & Langdon, 2011). In the rest of this paper I focus on this disagreement, but first, let’s take a look at the subjective structure of thought insertion.
3.1. Reports on Thought Insertion
These are classic reports on the conscious experience of delusions of thought insertion68:
Case 1: I didn’t hear these words as literal sounds, as through the houses were talking and I were hearing them; Instead, the words just came into my head – they were ideas I was having. Yet I instinctively knew they were not my ideas. They belonged to the houses, and the houses had put them in my head (my emphasis, Saks, 2007, p. 29).
Case 2: Thoughts are put into my mind like ‘Kill God’. It’s just like my mind working, but it isn’t. They come from this chap, Chris. They are his thoughts (my emphasis, quoted in Frith, 1992, p.66).
Case 3: I look out of the window and I think the garden looks nice and the grass looks cool. But the thoughts of Eammon Andrews come to my mind. There are no other thoughts there, only his. He treats my mind like a screen and flashes his thoughts onto it like you flash a picture (Mellor, 1970, p. 17).
Despite of the clear shortage of clinical reports, authors generally agree that there are five main features to this phenomenon:
(i) Negative aspect: Patients report that a certain thought present in their stream of consciousness does not belong to them (emphasis in case 1). Some people interpret this aspect as a thought lacking the phenomenal property of being mine or ‘sense of ownership’ (Fish, 1976; Campbell, 1999)69.
(ii) Positive aspect: Patients attribute the alien thought to an external agent that is not characterized as merely influencing the patients’ mental activity but rather, as actively placing a thought into their minds (cases 1, 2, and 3).
68 For more reports on the symptoms and a critical examination of its features, see the introduction of this compilation. 69 Fish (1976, p. 48) suggests: ‘Thinking, like all conscious activities, is experienced as an activity which is being carried out by the subject […] there is a quality of ‘my-ness’ connected with thought’.
89 (iii) Selectivity: The nature of thought insertion is selective in two senses. First, patients do not experience all their thoughts as inserted, but just some of them (selectivity type 1). Second, patients experience only certain types of mental states as alien, namely, feelings, emotions, thoughts and impulses (selectivity type 2).
(iv) Specificity: It seems that only a certain specific kind of thought-content is experienced as alien by psychotic patients. Gallagher (2004) suggests that alien thoughts are, most of the time, associated with significant others or with themes that are affectively relevant to the patients (also see Gibbs, 2000; Vosgerau & Voss, 2014, p. 554).
(v) Phenomenological Permeability: Episodes of thought insertion seem to be accompanied by a sense of permeability of ego boundaries. While experiencing inserted thoughts, the patient’s sense of ego-boundaries seems to get blurred as patients experience an external agent placing thoughts into their stream of consciousness70.
(iv) Lack of Causal Coherence: A feeling of causal coherence emerges when information concerning the triggering aspects of a certain thought are integrated to the occurrence of the thought (Martin & Pacherie, 2013). Causally integrated thoughts are experienced as ‘coherent and unified episodes of thinking’ (p. 115), and have a specific ‘phenomenology of coherence’ (p. 116). In contrast, inserted thoughts are first-personally experienced as ‘decontextualized’ or coming ‘out of nowhere’ i.e. having a phenomenology of discontinuity.
3.2. Two Doxastic Routes to Delusional Beliefs of Thought Insertion
There are a number of debates surrounding the characterization of delusions of thought insertion. For example, it is not clear if the sense of causal coherence alluded by some authors is something different from the sense of ownership that underlies conscious thinking in non- pathological situations or if they are one and the same (Seeger, 2013). Similarly, it is not clear if thought insertion really enjoys the specificity in content that authors like Gibbs (2000) and Gallagher (2004) tend to attribute to it. It is just not obvious whether it has the content of the delusion always has a special significance for the patient’s life (Graham & Stephens, 1994; cf. Gibbs, 2000)71. While sometimes this content can have a certain significance for the patient (case
70 The sense of ego-boundaries can be roughly characterized as a phenomenological demarcation between ‘me’ and ‘not-me’ (Parnas & Handest, 2003). 71 A further issue in this context is to define what ‘significance’ means. Most of the time, the term seems to refer to affective significance in terms of positive or negative valence towards certain intentional stimuli (see Gibbs, 2000; Fuchs, 2013; López-Silva, 2015).
90 2, assuming that the content
Most psychiatrists agree that the two key features of the delusional belief of thought insertion are its negative and positive aspects (Frith, 1992; Campbell, 1999; Mullins & Spence, 2003, p. 294; Bayne, 2013, among many others). The other features just make sense by referring to these more basic two. The relevance of the negative and positive aspects of delusions of thought insertion is that, without them, we might not even be able to characterize a certain delusional experience as thought insertion at all. A number of pathologies might involve problems in the experience of ego boundaries and sense of causal coherence, while also share the property of being selective and specific. However, what makes thought insertion so unique is that it involves the belief of an external agent placing thoughts into the patient’s mind. So to speak, the positive and the negative aspects of the delusion represent the paradigmatic scaffolding of the reports and it seems highly plausible to say that they both constitute the key means by which we can understand what this phenomenon is subjectively like. In this sense, paradigmatic reports of thought insertion involve the delusional belief with the content
3.2.1 The Explanationist Alternative
This option consists in claiming that a subject’s belief that a thought occurring in her stream of consciousness has been inserted by an external agent is the result of the patient’s attempt to explain the occurrence of a thought with abnormal features and relatively poorer propositional content. There are different ways to flesh out this claim. One alternative is to suggest that in thought insertion, patients are aware of a thought that is accompanied by irritating feelings of alienness or strangeness and, on the basis of these abnormal features, patients infer or
72 For a further treatment of these disagreements see the introduction to this compilation (section 3.1.).
91 judge that it is someone else’s (Synofzik, Vosgerau & Newen, 2008).
A second alternative is to suggest that patients do not agree with the content of a certain thought occurring in their stream of consciousness and they explain the thought in terms of external agency as the result of this conflict (Bortolotti & Broome, 2008; Pickard, 2010). A third alternative is proposed by Martin and Pacherie (2013) and consists, roughly speaking, in claiming that patients present a deficit in the ability to retrieve causal information about the occurrence of a thought and this is the basis for explaining the thought in terms of alien agency (contextual information integration deficit). Thus, the main idea within the explanationist model of thought insertion is that the belief
3.2.2. The Endorsement Alternative
The endorsement model of thought insertion claims that both the negative and the positive aspects of the delusional belief of thought insertion are loaded into the propositional content of the unusual experience grounding it. On this view, external attribution is part and parcel of the experiential state that underlies the delusional belief. Therefore, a subject’s belief that a thought occurring in her stream of consciousness has been placed in her mind by an external agent is the result of the subject’s endorsement of an experiential state with the same content (Sollberger, 2014)73. Here, alien attribution is a key experiential aspect of the state that grounds the delusional belief (Gerrans, 2001; Sousa & Swiney, 2011). As Sollberger (2014) claims:
What matters is that the patient arrives at the delusional belief B with the content
It is important to note that the endorsement alternative is not required to account for the direct, for example visual, experience of the external agent identified by the patients. Rather, this alternative only needs to account for the experience of a thought as being inserted by the specific
73 I take Sollberger (2014) as the main existing work trying to defend the plausibility of an endorsement model of thought insertion.
92 external agent. Some objections to this alternative conflate the problem about the propositional content of cognitive experiences with the issue about the actual subject’s perceptual awareness of the external agent74. Here is it plausible to claim that while ‘perception requires direct contact with the objects of one’s awareness, thought does not (Bayne, 2013, p. 4). As we can see, the endorsement model of thought insertion assumes that deluded patients trust the content of their own cognitive experiences just the way in which, in most cases, non-deluded people do. It supposes that patients literally experience a thought as being inserted by the specific agent they identify so the experience is just accepted as veridical. On this model, thought insertion patients form the belief that someone else inserts a thought into their minds simply because they endorse or take at face value an experiential state with a similar content (Heck, 2000).
There are two general preliminary issues that one needs to consider when distinguishing between endorsement and explanationist accounts.
First, we need to be careful at the moment of linking this distinction with the debate about the aetiological origin of delusional beliefs. The current dominant view on the psychogenesis of delusions of thought insertion establishes that the phenomenon is the product of deficits associated with the general process of formation of thoughts and beliefs (Stephens & Graham, 2000; Martin & Pacherie, 2013; López-Silva, 2015). The so-called deficit approach can be formulated in at least two fashions: (i) a one-factor deficit view claims that the only deficit that grounds the production of delusional beliefs is experiential. Here, the existence of a thought with aberrant features would be sufficient to produce a delusional belief since the mechanisms of belief-fixation would work as intended (see Maher, 1974). (ii) A two-factor view holds that apart from the necessary existence of an aberrant thought (factor-1), one needs to posit a cognitive deficit in the process of belief-fixation (factor-2). Here, the adoption of the delusional belief is not only the result of an experiential impairment but also the result of an additional cognitive impairment in the process of belief-formation (see Coltheart, 2002).
Some people might feel tempted to argue that while the endorsement model of thought insertion would be consistent with a one-factor account, the explanationist approach would be consistent with a two-factor account. By doing this, some people might tend to attribute the weaknesses and strengths of either of these deficit accounts to endorsement and explanationist models of thought insertion respectively. However, both endorsement and explanationist models can be formulated in these two different fashions. Advocates of the endorsement model might
74 This is the main reason why I have excluded Pickard’s (2010) objection from my main analysis. For a further examination of this issue, see: Sollberger (2014, pp. 602-606)
93 suggest that patients endorse the content of an abnormal thought (one-factor view) without appealing to any other deficit in the process of belief-fixation so the endorsement of the thought is just a rational response to the cognitive experience. They might also argue that the endorsement of the content of the aberrant cognitive experience is explained by a second-factor deficit in the process of belief-fixation so the patient is not able to reject the strange content suggested by the grounding experiential state (two-factor view).
Similarly, advocates of the explanationist alternative might suggest that patients explain the abnormal thought in terms of alien agency because such explanation seems consistent with the experiential evidence available (one-factor view). They might also argue that apart from the existence of an aberrant first-order thought, the type of explanation offered by patients is a product of a deficit on the process of belief-formation (two-factor view). As one can predict, all these alternatives present their own weaknesses and advantages; however, here I shall not address these problems since my aim is just to illustrate that both explanationist and endorsement models can be formulated in either one-factor or two-factor terms. Along with what Davies et al. (2001) and Pacherie et al. (2006) say, one should conclude that the distinction between one-factor and two-factor accounts regarding the psychogenesis of delusions of thought insertion is merely orthogonal to the distinction between endorsement and explanationist views.
Second, it is important to note that both the explanationist and the endorsement model of thought insertion formulate the role of the inferential transitions in the formation of delusions in a similar way as they both are doxastic approaches (Sollberger, 2014, p. 592). However, these two accounts differ in where they locate this transition. As Langdon and Bayne (2010) claims:
The explanationist account of the route from experience to a reflective delusion locates most of the inferential processing downstream of experience, in the processes of hypothesis generation and evaluation, whereas the endorsement account locates it upstream of experience, before the received delusion is endorsed (p. 331).
Once these issues are clarified, we can turn to the examination of which aspects of the delusional belief of thought insertion are really encoded in the representational content of the experience that grounds it.
94 4. Endorsement or Explanation?
4.1. The Non-Sensory Phenomenal Nature of Thinking
Before going further in the discussion, it is crucial to note that most of the arguments supporting explanationist models of delusions have been formulated in the context of the examination of the role of perceptual states in determining the content of certain delusions (Pacherie, Green & Bayne, 2005). In fact, explanationist accounts have become very popular in the context of the discussion of perception-based delusions such as Capgras and Cotard delusions (Young & Leafhead, 1996; Gerrans, 2002; Coltheart, 2002). However, Sollberger (2014) suggests that arguments coming from that context cannot be directly applied to undermine a potential defence of an endorsement approach to thought insertion. The claim is that delusions of thought insertion are grounded in introspective-cognitive experiences and not in perceptual experiences so there would be a fundamental difference in the nature of these two types of experience. The defender of the endorsement model claims that the belief that someone else is inserting a thought into my mind does not refer to experiences of mind-independent worldly objects and their properties as in the case of perception; rather, they refer to experiences of ‘conscious mental events that the subject is first-personally aware of’ (p. 597). The difference is that ‘the awareness-relation at stake holds between the subject and her own mental state. It is an instance of consciously based self-awareness and not, as in perception, of world-awareness’ (p. 598). The suggestion seems to be that while perceptual experiences need direct contact with the objects of one’s awareness, cognitive experience do not. However, the issue at hand here does not seem to concern the type of relatedness of these two types of mental states (although in some circumstances this issue might be an important one); rather, it concerns their representational nature, and given that both cognitive and perceptual states are representational states, it is plausible to think that some room for comparison can be allowed.
Now, the advocate of the endorsement model might clarify her case by suggesting that what it is like to perceive that P is very different from what it is like to think that P and in virtue of this difference in phenomenal character one should maintain a clear distinction between perceptual and cognitive states when approaching the explanation-endorsement debate. In this sense, the differences between perceptual and cognitive states become clearer, but again, one might be able to say that the shared representational nature of these two types of experiences seem to allow – although with some constraints – some parallelisms. Evidently, if arguments supposed to work in the context of the discussion of the nature of cognitive experiences rely exclusively on features that are only paradigmatic of perceptual states (for example, direct
95 contact with the content of the perception), a word of caution should be in place. An example of this is the problematic parallelism established between mental and bodily actions when discussing the sense of agency understood as willful generation of a certain thought or bodily movement (Frith, 1999; Gallagher, 2007; 2013)75. When applied to bodily movements, agency as wishful generation seems to make perfect sense (De Hann & De Bruin, 2010). In fact, we might distinguish between non-wishful bodily movements (like spams) and bodily actions in virtue of the existence of a sense of agency embedded in the very phenomenology of the latter phenomenon. However, such notion of agency does not seem to match the common phenomenology of thinking76: ‘the default mode of thinking is precisely not an explicit and willful generation of thoughts’ (De Hann & De Bruin, 2010, p. 383; see also Roessler, 2001). It is not my intention to argue for the implausibility of this parallelism further in this place77; the point I’m trying to make is that although one might be able to apply some arguments from the discussion of other types of mental states to the explanationist-endorsement debate of thought insertion, this move should be always justified. In cases, comparisons would work; in some others, they might not.
A second problem here might be that the point that the defender of the endorsement model is trying to make seems to require the phenomenology of thinking to be distinguishable from the phenomenology of perceptual states in a very distinctive way. However, sometimes, clear phenomenological distinctions become problematic. Take the case of synaesthesia, i.e. the experience of ‘seeing sounds’ or ‘smelling colours as odours’, etc. (Blakemore et al., 2005). Research suggests that experiences of this kind are empirically possible (Hubbard & Ramachandran, 2005). What this type experience shows is that it is possible that different experiential modalities can overlap under certain pathological circumstances. Now, in the case of thinking the same seems to apply, at least, in the context of psychosis:
The things that are ‘thought’ in this way do not belong to the mad person as thoughts would belong to normal people. During madness, thoughts are more like inspirations or epiphanies that come from outside, that are experienced as strange and for which the mad person is not responsible. He rather feels like the thoughts present themselves to him rather than that he thinks them. He can be ‘surprised’ by thoughts. Like we would normally be surprised by thoughts that we read in a text, in the same way the mad person can be surprised by the thoughts that he reads or experiences in his own mind (Kusters, 2014, p. 105).
75 For an empirically and philosophically well-informed discussion of many issues related to this parallelism, see: O’Brien & Soteriou (2009). 76 I thank Prof Dr Thomas Fuchs for suggesting this point. 77 For a discussion of this idea, see Paper 1 of this compilation.
96 Kusters (2014) reports that in the period preceding his own episodes of thought insertion, the whole experience of thinking becomes transformed as thoughts seem to acquire perception- like phenomenological features. More specifically, about thoughts, Kusters (2014) claims that ‘you can even feel them stream away through your hands or your head’ (p. 105). Some other times, the author claims to have experienced her own thoughts as ‘object-like’. Normally, thoughts are claimed to have neither colour nor sound; however: ‘in madness they become more sense-like and may for example have shape and colour’ (p. 105). Similarly, Cahill and Frith (1996) refer to a patient that claimed to have physically felt the alien thoughts as they entered in his head and claimed that he could pinpoint the place of entry (p. 278). Although there seems to exist some relevant phenomenal differences, it can be also claimed that, in the context of psychosis, cognitive states like thoughts can become like the objects of sensory perceptions. In turn, this suggests that some comparisons might be allowed between these states.
Finally, it is important to note that these reports offer prima facie evidence neither for an explanationist nor for an endorsement model of thought insertion. What they do show is that we should not rule out so easily certain arguments – such as those coming from the endorsement- explanationist debate of perception-based delusions – purely based on sharp phenomenological distinctions unless such distinctions can be further argued. A more fruitful path is to examine whether particular arguments coming from different discussions can work in different contexts rather than rule all of them out at once78. Finally, it might be argued that, in some cases, the experience that grounds thought insertion preserves a phenomenology closer to the phenomenology of paradigmatic cognitive experience, while in some others, that cognitive experience can phenomenologically overlap with the experiential features of perception-like states. All that the existence of this phenomenological diversity would show is, perhaps, that while some delusions can be adopted via endorsement of clear experiential states, some others might be adopted via explanation.
4.2. Subjective Certainty
One of the general strengths usually attributed to endorsement models of delusions is that they can plausibly explain the subjective certainty that seems to characterize delusional reports (see section 2). The idea is that if we are asked to explain why one holds the belief
78 I myself have argued for a relevant phenomenological distinction between cases of auditory hallucinations and thought insertion (López-Silva, 2015). Often, phenomenological reports seem to support this distinction (Nayani & David, 1996).
97 grounds that belief and such natural endorsement of the relevant experiential state would be the basis of the certainty with which the belief is reported. In the case of thought insertion, the subjective certainty shown in the reports might be nicely explained by patients having the actual experience of a thought as being inserted by someone else, which in turn, would reinforce the belief and explain its incorrigibility over time without treatment. In contrast, explanationist models might not be able to explain this certainty because beliefs adopted via explanation would be associated with a slower onset of subjective conviction. A subject might form the belief with the content
It is tempting to tip the scale in favour of the endorsement model here. However, such conclusion seems too hasty. As mentioned in section 2, subjective certainty is a matter of degrees. The problem is that the endorsement defence implies that all cases of thought insertion are reported with the same high degree of subjective certainty or at least, with the same degree of certainty as those beliefs acquired via endorsement. However, this is not always the case. Different cases of the same delusions can be reported with variable degrees of subjective certainty (Parnas & Handest, 2003). De Hann and De Bruin (2010) claim that in some cases, patients report their delusional episodes ‘as if’ they were the case: ‘it is as if my girlfriend can read my thoughts […] it is as if I am from another planet (p. 385, note 16). In many cases, patients are not entirely sure of what is going on with their experiential world and in that context, the delusional belief might arise as a way of making sense of the patients’ confusing experience of their inner and outer world (Mishara & Corlett, 2009). Here, I’m not implying that there is no relevant grounding experience in the formation of the delusion, but rather, that it is plausible to thing that in some cases this experience can be vague and confusing with respect to its representational content (Coltheart, 2002). This suggestion is also phenomenologically appealing. It is claimed that in many occasions, the adoption of a delusional belief can be compared with the moment one finds an explanation after a period of overwhelming doubting and enquiring (see Conrad, 1958). Mishara (2010, p. 2) suggests that some delusions arise as ‘revelations’ or as ‘aha experiences’. This phenomenological quality seems to suggest that those delusions might be adopted via explanation and that in those particular cases at least, subjective certainty would
98 appear later in the process of the adoption of the delusional belief.
In this context, the explanationist might explain the incorrigibility of delusions, perhaps, as either the incorrigibility of an explanation that is playing an important role in unifying the experiential world of the patients (Mishara & Corlett, 2009)79 or as the incorrigibility of a delusional belief that has been adopted motivated by the role it plays in the patient’s attempt to deal with a psychological conflict (Gibbs, 2000; Bell, 2003; Bortolotti, 2014). However, as we will see, both options do not really explain the nature of the explanation meant to make sense of the bizarre experience. Either way, what is clear is that the existence of these variable degrees of subjective certainty posits a challenge to both the endorsement and the explanationist views of thought insertion.
4.3. The Ambivalence Problem: To be, or not to be?
The endorsement model seems to face another problem that is in strict connection with the point just made about subjective certainty. Parrott (2012) claims that reports of thought insertion are characterized by the existence of certain ambivalence in the patients. Parrott quotes Frith’s patient who claimed that in thought insertion ‘it’s just like my mind working, but it isn’t’ (1992, p. 66), and Allison-Bolger’s case (1999, #68) when she says: ‘own thoughts might say the same thing . . . but the feeling isn’t the same . . . the feeling is that it is somebody else’s’. Parrott’s objection is that the endorsement alternative becomes implausible in the face of this phenomenon because it needs to pack all the abnormality of the symptom into the representational content of the subject’s experience, then:
[A] defender of the [endorsement] account could try to capture this ambivalence, but I think an attempt to do so will face additional problems. This is because it is obscure how the ambivalence of a schizophrenic person's report could be represented in the content of her experiences. How are we to make sense of an experience that represents both a thought being inserted and it being "just like my mind working"? These two elements seem to be contraries. How could they both be simultaneously represented in the content of an experience? (p. 11)
In Parrott’s opinion, it is just implausible to think that experiences can have the type of representational content that the endorsement model requires to explain this ambivalence, namely, experience with the content of the type (P&¬P). Let me unpack Parrot’s point. First, I think it is crucial to distinguish between a feeling of ambivalence that pervades the patients’
79 For a further development of this idea, see Paper 5 of this compilation.
99 report and the ambivalence in the representational content of the grounding experience with the form (P&¬P). Second, Parrot’s stronger claim seems to be that, within the endorsement model, the former element is explained by the latter and then: ‘it is obscure how the ambivalence of a schizophrenic person’s report could be represented in the content of her experience’ (Parrot, 2012, p. 10). It may be that psychotic patients have an experience like this, but, if so, it is far from coherent. Thus, by supposing that every component of what a psychotic patient reports is somehow represented in the content of their experiences, the endorsement account would lead to an obscure understanding of the phenomenon. The defender of the endorsement model can reply to the ambivalence challenge in two ways.
The first way is to deny Parrott’s stronger claim: it is possible to explain the reported feeling of ambivalence not necessarily in terms of the experiential content of the grounding experience. Rather, the endorsement theorist might suggest that such ambivalence can be plausibly explained by appealing to other features of the phenomenon. Sollberger (2014) claims that: ‘one such feature would be the patient’s experiencing a dissociation between SoO [sense of ownership] and SoA [sense of agency]’ (p. 607). In thought insertion, Sollberger argues, the thought in question would be experienced with a normal sense of ownership and without a sense of agency (this is the so-called ‘standard approach to thought insertion’; Frith, 1992; Sousa & Swiney, 2011; Gallagher, 2014). Patients would be ‘owner-aware’ but not ‘agent-aware’ of a thought and this dissociation might account for the feeling of ambivalence present in the patient’s reports. This reply looks attractive but it has some problems80.
The first is that the alleged dissociation between sense of ownership and sense of agency is not itself an experiential feature of the phenomenon, but rather an interpretation of it; it’s just a way of making rational sense of the patient’s reports. When approaching delusions, one should distinguish between what the patient says from how we interpret those reports. Here, an interpretation ‘is concerned with the reasons the patients might have – or fail to have – for their delusional speech’ (Billon, 2015, p. 6). The defender of the endorsement can recognize this subtle issue and reply that, even if the ownership-agency dissociation is an interpretation of the delusional speech of the patients, such an interpretation explains in a plausible way the feeling of ambivalence alleged by Parrott as it targets what patients feel in cases of thought insertion. Here, one needs to keep in mind that the main aim of the endorsement reply at this moment is to explain the ambivalence referred to by Parrott without appealing to the representational content of the cognitive experience grounding the belief, and, in this sense, the reply seems to do its job.
80 Some of the main problems of this approach have been treated in the first paper of this compilation.
100 Some explanationists might suggest that the real problem with this reply is that this specific interpretation of thought insertion has received a number of objections over the years (see for example; Bortolotti & Broome, 2008; Martin & Pacherie, 2013); so, in replying to the ambivalence challenge, the defender of the endorsement model assumes a problematic interpretation of thought insertion. Let me clarify this point. One of the most relevant problems of this interpretation of thought insertion for the endorsement theorist is that a lack of sense of agency with a retained sense of ownership does not secure that the external attribution aspect is part of the grounding cognitive experience of thought insertion. There is an important difference between becoming aware of a thought merely as not being intended from becoming aware of a thought experienced as being created by someone else. The endorsement alternative needs to pack the latter rather than just the former aspect into the grounding experience of the delusional belief. Nonetheless, a number of our thoughts are experienced as unbidden i.e. as suddenly popping into our stream of conscious without an associated sense of agency (Martin & Pacherie, 2013). As Frankfurt (1976) concludes, some of our thoughts ‘strike us unexpectedly out of the blue’ (p. 240). For the sake of the discussion, let’s assume that the distinction between sense of ownership and sense of agency is a plausible one in the case of thinking as well as in the case of bodily movements. In the case of an unbidden thought, one might uncontroversially suggest that ownership over the thought in question is retained while its sense of agency is missing just as in the case of thought insertion within the standard approach. However, although we cannot identify any sense of agency for the unbidden thought, it is not externalized as in cases of thought insertion.
Prima facie, this might suggest that, apart from this dissociation, thought insertion patients would explain such dissociation in terms of external agency. Recently, Billon and Kriegel (2014) have claimed that an inserted thought qua inserted instantiates all the phenomenal properties of a normal thought but in addition, it has an extra phenomenal property: it feels inserted (p. 16). Is this idea useful for the endorsement theorist? It seems not. The problem for the endorsement alternative is that it needs to pack the whole content of the delusional belief in the experience that grounds it (i.e. a thought T as being inserted by S) so feeling just inserted it is not sufficient for the endorsement theorist to make his case. In contrast, an explanationist might simply suggest that patients do feel inserted thought as inserted but the external attribution aspect of the belief (inserted by P) is an explanation for this experiential feature of the grounding thought81.
However, there is a second way in which the endorsement theorist can reply to the
81 This claim is consistent with the affordance model defended in the first paper of this compilation.
101 ambivalence challenge. Based on Bleuler’s work, Sollberger (2014) appeals to the patient’s background knowledge to account for the feeling of ambivalence identified in the patients’ reports. The idea is that psychotic patients can distinguish between their delusionary world and the real world and ‘this sort of double-awareness might arguably give rise to a competitive tension between, on the one hand, endorsing the delusional experience and, on the other, not endorsing it’ (p. 607). One of the problems with this reply is that such doubting at the moment of endorsing or not endorsing a certain experience is not consistent with the degree of subjective certainty that the endorsement alternative attributes to delusional reports (see section 4.2.). This model puts subjective certainty as a feature of the early stages of the symptom’s onset and this explanation of the feeling of ambivalence does not match this picture. It seems more sensible to say that, given this ambivalence, subjective certainty would come later in the development of the symptom, but such a view is more consistent with an explanationist view, apparently.
As it stands, it is not clear how this reply can explain the feeling of ambivalence identified by Parrott. The endorsement theorist seems to be well aware of this issue and elaborates a second strategy that consists in simply accepting that the feeling of ambivalence can be grounded in the experiential content of the delusion while denying that this issue is problematic. Sollberger (2014) appeals to the ‘waterfall-illusion’ to argue that it is possible that some perceptual states represent contradictory contents. Usually, this illusion is taken to instantiate a case where a perceptual experience represents something as both moving and not moving (Crane, 1988). There are a few issues about this suggestion. First, one might resist such a way of characterizing the phenomenon (see for example, Mellor, 1988). In fact, the whole discussion about the waterfall illusion seems to be premised in an oversimplified phenomenological description of what happens in this case for it is just not clear if one actually experiences the elements of the image as moving and not moving simultaneously. Such an interpretation seems odd. It might be the case that one experiences P as moving and as not moving at different moments by quickly shifting the focus of visual attention and by increasing the inclusion of peripheral aspects of the field of visual awareness into the different perceptual inputs of the image. A second option is to say that one can experience different aspects of the illusion as moving and as having moved (Mellor, 1988).
Thus, one might be able to resist the claim about the simultaneity of the two aspects allegedly implicated in this visual illusion. Certainty, a further discussion of this issue would take us too far from the main debate, but the point is that the acceptance of the fact that the feeling of ambivalence can be grounded in the representational content of experience of thought insertion is
102 a controversial issue. Perhaps, such a scepticism about Crane’s interpretation of this perceptual state is not needed as the explanationist might simply reply by saying that even if this type of experiences are possible, they can only occur in cases of perception. Perhaps this type of experience can be instantiated exactly because of the mind-independent nature of the stimuli they represent (perpetual experiences require direct contact with its objects, unlike cases of thinking). In any case, the point is that it is not obvious that one can experience such ‘conjunctive’ states in cases of thinking. What it is not controversial is to say that all that the ‘waterfall-illusion’ shows is that one can experience something that is not really moving as moving. However, given that simultaneity is a requirement for the endorsement reply in terms of the possibility of contradictory experiences to work, appealing to the waterfall illusion does not obviously help.
There is a final issue that remains unresolved. Even if cognitive experiences with contradictory representational content exist, the reply does not make sense of why patients would uncontroversially endorse such experiences. Even if these experiences were possible, they may not be quickly endorsed. Again, the issue of subjective certainty plays a crucial role here. However, I shall not repeat this point since has already been made. One of the main problems is that the general endorsement defence seems to be premised in the idea that deluded patients trust their experiences just the way non-deluded patients do. Such an idea is not unproblematic. In a recent interview with Roberta Payne about her episodes of thought insertion, she claims:
No, I did not trust my experiences in a normal way in the period of time leading up to this delusional period of aliens and rules. In the months preceding it, I experienced unreality many times […] I had other experiences in which I had to, for instance, touch a coffee table in front of me to make sure it was real. I had short times in which nothing outside myself seemed to exist: I told my psychologist that it felt like the world I was observing was like wallpaper (Payne, 2015).
The endorsement assumption seems to be in clear conflict with the way in which at least some thought insertion patients approach their own experiences. In this sense, an explanationist account seems to be in a better position to make sense of the way some patients approach their experiential states in periods that precede the adoption of delusional beliefs of thought insertion. Does this mean that an endorsement model cannot really reply to the ambivalence challenge? No, it does not.
Perhaps a more fruitful path to be taken by the endorsement theorist is to claim that the feeling of ambivalence identified by Parrott is just not characteristic of all cases of thought
103 insertion. In fact, this option seems to be consistent with some of the patients’ reports available in the literature (see Mullins & Spence, 2003). While it is true that some patients do show certain ambivalence in their reports, it is not the case that this feature is part of all cases of this delusion. Just as in the case of the discussion about the variable degrees of subjective certainty of different reports of the same delusion, one might be tempted to suggest that delusions reported with feelings of ambivalence might be endorsed via explanations of vague grounding experiences, while those reported without – or with low degrees of – feelings of ambivalence might be endorsed via endorsement processes. In this sense, Roberta’s case would be an example of the former modality of adoption of delusions of thought insertion82.
4.4. The Experiential Encoding Problem
As we have seen, doxastic models of delusions of thought insertion need to account for at least two things: (i) the content of the abnormal cognitive experiential state that grounds the delusional belief and, (ii) the content of the doxastic state (belief). In doing so, both endorsement and explanationist models face different empirical and conceptual challenges. Here are two final issues:
4.4.1. The Incredibility Objection
Often, it is suggested that explanationist models have an easier job in explaining the content of the grounding cognitive experience of thought insertion because the less one packs into the content of this experience, the easier it is to account for how such experiential state acquires its content (Pacherie, Green & Bayne, 2006, p. 567). This has been called ‘the experiential encoding problem’. Parrott’s objection (section 4.3.) seems to be just one of the many formulations of this problem available in the literature. The idea is that, when making sense of delusions of thought insertion, it is unproblematic to think that certain thoughts might be able to convey the vague content ‘this thought is not mine’. One can clearly agree that this type of cognitive experience is actually quite possible even in non-pathological cases. A problem here, an explanationist would say, is that the endorsement theorist needs to appeal to the existence of cognitive experiences of the specific type ‘this thought T has been inserted by S’, and this is taken to be a very implausible move (see Vosgerau & Voss, 2014)83.
82 The issue about which modality is more common is an open question and the answer to it seems to depend on the examination of the psychological architecture of the subject and the phenomenological context in which the delusion is adopted. 83 As we can see, this problem is slightly different from the one pointed out by Parrott (2012), which focuses on how the endorsement model would struggle to explain experiences with the content of the form (P&¬P).
104 There are two more ways in which this problem can be formulated. The first consists in claiming that the type of cognitive experience with the content ‘this thought T has been inserted by S’ is just impossible, period. This has been called the ‘incredibility-objection’. One should be careful with objections of this kind since psychotic experiences seem to challenge our most basic notions about mental life. Now, it is not clear in this objection why exactly the type of experiences required by the endorsement model should be considered as impossible in principle. Sollberger (2014) seems to suggest that this objection relies on a certain lack of empathy when he asks: ‘Is it only because people who are lucky enough not to suffer from inserted thoughts fail to imagine what such experiences could be like?’ (p. 598). If this is the point, the defender of the endorsement model might reply that there are several ways in which we can make rational sense of psychotic symptoms and, therefore, make sense of how certain types of (prima facie implausible) experiences can occur. Moreover, the whole discussion about the experiential routes to delusional beliefs is premised on this basic idea.
More specifically, in replying to the incredibility objection, Sollberger (2014) again appeals to the distinction between sense of mental ownership and sense of mental agency already mentioned in section 4.3.. I have already pointed out that this interpretation is subject to a number of objections. However, the point that the advocate of the endorsement model is trying to make here is just that there are rational ways of making sense of experiences of thought insertion or, in other words, that there are many ways in which experiences of thought insertion can become intelligible. Certainly, the standard model is not the only means availably to undergo this task. The real problem is that the endorsement theorist does not prove that the type of experience that he requires can become intelligible by appealing to the standard model of thought insertion, the tenability of which is the main issue at hand.
As seen in section 4.3., lack of sense of agency does not entail external agency (of the type required by the endorsement model) as part of the representational content of the experience that grounds the delusions of thought insertion. In fact, the dissociation of ownership and agency seems to favour an explanationist model within which the type of contents assigned to grounding experiences is less demanding (Vosgerau & Voss, 2014). Now, the advocate of the endorsement model might reply by saying that the relationship between ownership and agency can also be formulated in endorsement terms (see Gallagher, 2007). However, if this is the case, all it shows is that the ownership-agency relationship can be formulated in either endorsement or explanationist terms, so it does not give the endorsement model any privileged position over explanationist views.
105 In formulating a second reply to the incredibility objection, the endorsement theorist appeals to cases of synaesthesia (see section 4.1.). For a long time, it was claimed that experiences of synaesthesia were not genuine cases of perception (perhaps, another case of the incredibility objection but in the context of perception). Synesthetic experiences were often taken as cases of imaginings, quick verbal associations, or as the result of extreme uses of metaphors. However, as mentioned before, researchers have shown that synaesthesia is a genuine perceptual experience. The endorsement defence concludes that, just as in cases of synesthetic experiences, it is plausible to think that there is something that is like to experience a thought as inserted by an external agent. In clarifying his point, Sollberger (2014) compares a blind subject trying to understand what it is like to perceive colour:
Likewise, people who have never experienced inserted thoughts may fail to know what it is like to be first-personally aware of a thought that is woven into one’s consciousness as belonging to another cognitive agent. But this lack of first-personal knowledge does not imply the bare impossibility of such experiences. Much more needs to be said in order to reach that conclusion (p. 599).
This comparison looks problematic. All that synesthetic experiences show is that it is plausibly the case that there is something that is like to see sound as colours or to smell colours as odours, and so on. The problem is that these experiences are not close to the type of experiential representational content the endorsement theorist needs to account for in cases of inserted thoughts. If we establish this parallelism in the right way (just for the sake of the discussion), the type of perceptual experiences that Sollberger should be comparing would be something like: ‘I am aware of being smelling colours as odours, and this state has been inserted by an external agent’. However, the types of experience equated by Sollberger seem rather different in terms of their representational content. As it stands, the reply does seem to help the endorsement model to make its case about the existence of the type of cognitive experiences it requires to make sense of thought insertion.
4.4.2 The Non-Agency Objection
The second way in which the experiential encoding problem is formulated can be referred as the non-agency objection. This objection is in strict connection with the reply offered by the advocate of the endorsement model to the incredibility objection. Perhaps it might be possible for a subject to experience her own thoughts as not being hers but not as being someone else’s. Synofzik, Vosgerau and Newen (2008) explain that, in thought insertion, the sense of non- agency is coupled with feelings of irritation. These feelings of irritation would explain the extra
106 reasons that patients have to explain the thought in question in terms of external agency (not as in cases of unbidden thoughts for example). The claim is that in such an ambivalent situation, the patients feel the urgent need to explain what is going on and external attribution arises as an explanation for such a stressing situation: if this is not mine, it must be someone else’s.
The first reply coming from the endorsement camp is to suggest that ‘it is not mandatory to explain alien agency in non-experiential terms’ (Sollberger, 2014, p. 599). But this reply is not very helpful. One might say that just as it is not mandatory to explain alien agency in non- experiential terms; neither is mandatory to explain it in experiential terms but the whole issue of the debate is to clarify whether external agency is part – or not – of the cognitive experience that grounds delusions of thought insertion. So, appealing to ‘mandatory’ things does not really do much in this context. This reply removes all the importance of this debate. Here’s a better reply by the endorsement theorist: One does not need to characterize a sense of mental agency in a disjunctive fashion, namely, as either ‘I’m the author of this thought’ or ‘I am not the author of this thought’. Sousa & Swiney’s (2011) characterization of thought insertion suggests that apart from the absence of self-agency there is a sense of alien agency attached to the underlying experience of thought insertion. The problem is that it is not clear what a sense of alien agency really means. An explanationist might suggest that this is still a really vague experience and that ‘alien agency’ does really involve having the experience of a thought as being inserted by the specific agent that patients refer in their reports. The other possibility is to recall Billon and Kriegel’s suggestion about a thought experienced as ‘being inserted’, but again, this is not enough for the endorsement theorist to make his case. The challenge here is, therefore, to explain how this sense of external agency – whatever that is – transfers to ‘Chris’, ‘Eammon Andrews’, or any of the external agents identified by the patients as the responsible of their inserted thoughts. This last issue, again, seems to point to the need to characterize the process of adoption of delusions of thought insertion as the result of a number of endorsement and explanationist strategies within a single subject.
4.5. The Doxastic Encoding Problem
The endorsement alternative seems to be in better position to explain how the content of delusional beliefs of thought insertion is acquired. After all, experiences with more specific and richer content seem to posit more constraints in structuring the beliefs they ground. As Langdon & Bayne (2010) claim: ‘by contrast, advocates of a purely explanationist account need to work much harder in order to explain the generation of the delusional content, for on such an account the gap between experiential content and delusional content is wider’ (p. 333). Let’s call this the
107 ‘doxastic encoding problem’. The problem for the explanationist is that if a patient simply has a cognitive experience of a thought that is not hers with some other additional features (irritating feelings, being inserted, etc.), why does she then form the belief the relevant thought has been inserted by an external agent? While the endorsement theorist suggests that this issue can be nicely explained by the patient having a cognitive experience with the same content, the explanationist claims that delusional beliefs of thought insertion emerge as the patient’s attempt to explain an unusual experience. However, as Pacherie, Green & Bayne (2006) point out ‘the problem with this suggestion is that delusional beliefs are typically very poor explanations of the events that they are supposedly intended to explain’ (p. 567)84. Allegedly, more plausible explanations of the same strange experience that patients are undergoing would be available, ‘some of which might be actively recommended to them by family and medical staff’ (p. 567).
The explanationist reply might consist in asking back: why exactly should we expect psychotic patients to offer the same type of explanations that non-delusional patients are expected to offer? After all, a number of other problems (perceptual, motivational, or purely neurocognitive) can influence the type of explanations that patients entertain to make sense of their experiential states. A suggestion along the same lines is to say that it is not obvious that, at the moment of experiencing the abnormal cognitive experience, patients always have other – better – explanations available. It has been noted that a number of delusional beliefs are adopted within contexts of profound affective and perceptual transformations (Fuchs, 2005; Marwaha et al. 2014; López-Silva, 2015). Marwaha et al. (2013, p. 6) claim that ‘the sense that emotional experiences are out of one’s personal control may prompt a search for meaning that may find explanations in terms of external influence’. In our interview, Roberta Payne comments that the period of time preceding her episodes of thought insertion was characterized by a total transformation in the way she perceived her inner and outer reality. This phenomenon is called delusional atmosphere and is a period in which ‘patients feel uncanny and that there is something suspicious afoot’ and where ‘everything gets a new meaning’ (Jaspers, 1963, p. 98). During this period, everything (outer and inner reality) is experienced as strange (Sass, 1992), everything looks unreal (Gross & Huber, 1972), and the entire world losses its predictability (Fuchs, 2005; Mishara & Corlett, 2009)85. In this context, thoughts are experienced as coming out of the blue (see Kusters’s quote, 2014, p. 105 in section 4.4.2). As a consequence of all these changes patients stop trusting their own experiences and an increased need for closure arises (Mckay,
84 This point has been formulated in the context of the examination of perception-based delusions. However, the suggestion also applies in cases of thought insertion. 85 For a further description and discussion of this phenomenon, see Paper 5 of this compilation.
108 Langdon & Coltheart, 2007)86. In midst of all these changes, it is not clear if patients have better explanations of their experiences available; even if better explanations are available, it is not clear whether patients can become aware of them. As Martin & Pacherie (2013) comment: ‘extraordinary events call for extraordinary explanations, so to speak’ (p. 121).
Here, apart from suggesting that the content of experiences is less specific in these situations, the explanationist might claim that patients arrive at explanations in terms of external agency as a way of infusing some basic order to their already disorganized field of awareness (see Mishara, 2009; Mishara & Corlett, 2009). Patients elaborate these explanations because they constitute the only type of explanation they can elaborate under such overwhelming circumstances. Thus, the delusional explanation would imply a quick way out from this general state of experiential disorganization. However, the endorsement theorist can suggest that this reply still does not explain why exactly this is the only type of explanation that patients can elaborate to render their field of awareness more experientially organized. Again, the explanationist can say that it is not clear whether we should expect from psychotic patients the same type of explanation offered by the non-psychotic. Perhaps the bizarre nature of the delusional explanation elaborated by psychotic patients can be accounted in terms of different doxastic styles. Pacherie, Green & Bayne (2006) point out that two normal subjects could reason from exactly the same types of experiential states to quite different doxastic states depending upon their personal doxastic styles. It can be the case that only one of these subjects stresses mechanistic explanations while the other does not. Similarly, the bizarre nature of the explanations formulated by patients can be accounted for in terms of exaggerated doxastic styles in conjunction with their overwhelming experiential circumstances. However, a lot more needs to be said by the explanationist for this suggestion to become more challenging.
There are two final suggestions that the endorsement theorist might make. First, it is possible to recognize that some delusional beliefs of thought insertion are in fact adopted in the context of profound affective and perceptual alterations, but at the same time, the endorsement theorist might insist in suggesting that they are adopted just because certain thoughts are experienced as being inserted by external agents. The problem is that this does not seem to be the case during delusional atmospheres where the information regarding the causes of the different mental states of a subject is mostly missing (Conrad, 1958; Fuchs, 2005). In fact, during this period patients experience a pervading feeling of passivity, which, in turn, seems to be based on
86 This seems to be consistent with the explanationist account of thought insertion formulated by Synofzik, Vosgerau and Newen (2008).
109 the lack of awareness of the agency of their different mental states (Sass, 1992; Wegner, 2002). The final suggestion that the endorsement theorist can make is to say that while it is true that the adoption of delusions of thought insertion is preceded by a number of phenomenological transformations in some cases, this does not apply to all cases. However, this does not do much to explain how experiences with the type of representational content required by the endorsement theorist can be possible at all.
5. Towards a Potential Solution: Thought Insertion as Hybrid Delusional Beliefs
As the analysis shows, both explanationist and endorsement models of thought insertion face different explanatory challenges and differ in their weaknesses and strengths. As it stands, the debate is far from resolved and this is, I believe, because it has been mostly formulated as a dichotomy: while some people argue that thought insertion should be exclusively explained in an explanationist fashion, others claim that this should be done so in exclusive endorsement terms. When considering the complexity of our mental life however, such dichotomies are not always helpful. Hence, I will argue that the solution to our target dispute lies on finding a middle ground between the two main alternatives analysed.
A first integrative option here might be to claim that, in some cases, delusions of thought insertion can be adopted via endorsement while, in some others, they can be adopted via explanationist mechanisms87. On this option, delusions adopted via endorsement would be those grounded in experiences that preserve phenomenological features closer to paradigmatic cases of cognitive experiences, while those adopted via explanation would be those grounded in cognitive experiences having phenomenological features that overlap with, for example, other experiential modalities. Similarly, those delusions adopted in the presence of the external agent would be more likely to be adopted via endorsement (Saks, 2007), while those adopted in absence of it might be more likely to be adopted via explanationist mechanisms (Payne, 2013). Another way of making sense of this option is by suggesting that delusions adopted via endorsement would be related to higher degrees of subjective certainty, while those adopted via explanation would be related to ambivalence and variable degrees of subjective certainty. At first, this option seems very attractive because it seems to make everyone happy. While sometimes we can use an explanatory model, some other times we can appeal to an endorsement one. However, this option is still argumentatively problematic because it does not do anything to overcome the particular
87 This idea has been explored in the context of the discussion of the relationship between delusions and confabulation (Langdon & Bayne, 2010), and in the debate about the adoption of delusional beliefs of Capgras (Davies, Coltheart, Langdon & Breen, 2001). In the context of thought insertion, a challenge here would be to clarify the commonalities between different single cases but that task exceeds the scope of this article.
110 objections against each view involved in the debate88.
Let me explore a more plausible integrative alternative. As stated earlier, cases of thought insertion vary considerably in terms of subjective certainty, ambivalence, heterogeneity of the alien owner of the thought, phenomenological context, and so on. However, a key distinction that is often overlooked is that that delusions – as well as beliefs in general – differ in the degree of complexity of their propositional content. The belief with the content
Here, I propose that a plausible option to explain the many ways in which delusions of thought insertion are heterogeneous is by suggesting that the two modalities of adoption of delusions work together in the formation of single beliefs. This is not an implausible idea because, after all, these two modalities aim at implementing a subject’s representation of a particular internal or external state of affairs as actual. From this point of view, delusions of thought insertion are better understood as being adopted through the conjoined action of both endorsement and explanationist mechanisms of belief-adoption just like in some cases of non- delusional complex beliefs. Consider the case of the belief
Taking this idea into account, I maintain that single delusions of thought insertion contain various propositional contents (just like in the just aforementioned example) that can be distinguished in the patients’ report. Some of these contents would be arrived at via an
88 This is by no means to say that such a proposal cannot be applied to other less complex cases of belief. Take the case of a subject S who holds the belief that he has heard God’s voice. S could have adopted this belief by using either the endorsement or the explanationist modality. S could have experienced the sound of the wind or some other auditory input as being God’s voice. This would certainly depend on S’s background knowledge, set of – not only religious – beliefs, affective states, mood, expectations, and a number of other factors. Perhaps S has been having a difficult time and, being a religious man, S was expecting to receive a sign from God. The point is that a number of affective, cognitive, phenomenological, and even cultural factors might have led S to hear a certain sound as God’s voice. Now, S could have experienced just a rather unclear and ambiguous sound that could have been taken as God’s voice by him. Again, such an explanation would depend on the aforementioned factors.
111 explanationist route whereas others would be arrived at via an endorsement route. This is to say that we should think of single cases of delusional beliefs of thought insertion as being doxastic hybrid state. The claim here is not that one modality works for some cases while the other works for the rest. Rather, the suggestion is that when patients come to adopt delusions of thought insertion, they do so by way of these two modalities working in parallel. This hybrid option seems to be in good place to explain the variable degrees of certainty of the way delusions are reported and, more importantly, it seems to avoid the objections such as the experiential and doxastic encoding problem. Instead, the main challenge of a potential hybrid model would be to specify which aspects of the delusional belief are acquired via endorsement and which ones of them are acquired via explanation. In the remaining of this section, I shall explore some ways in which a hybrid model might be formulated.
Consider the case of a patient who claims that the radio has placed a thought in her mind. Before this is reported, the subject’s might feel strange, experiencing random unconnected thoughts, memories, perceptual states, and so on (see Sacks, 2007). During this period, the subject might start experiencing a profound permeability in the distinction between inner and outer reality (Payne, 2015). Gradually, the experience of herself and the world become blurry. During this pre-delusional period of experiential confusion the subject experiences a thought as not being hers (and inserted) and a visual or auditory experience of a radio. A hybrid model would propose here that the subject endorses those two experiential states separately, but in trying to make sense of the dominant phenomenological confusion, a delusional explanation puts them together, leading up to the final content of the doxastic state reported by the patient (see for example, Mishara, 2010). In this specific case, both the thought and the external agent would be present in the subject’s field of awareness, but they would be tied together in a delusional explanationist move. A potential objection here is to claim that not all delusions of thought insertion are adopted in the context of these more general alterations in consciousness. For example, those resulting from brain damage. First, it is not clear whether thought insertion can be associated with brain damage. Second, thought insertion is usually taken to be a psychotic delusion and from this point of view, it is important to note that most psychotic patients adopt delusions in the context of an importantly fragmented experience of themselves and the world (Silverstein & Uhlhaas, 2004; Uhlhaas & Silverstein, 2005). In fact, accounts of the context in which thought insertion emerge seem to support this idea (Saks, 2007; Payne, 2014)89. Finally, to deny this is to overlook one of the most crucial aspects of the occurrence of most psychotic delusions. In fact, Jaspers (1963) considers this altered phenomenological context in which
89 For a further examination of this issue, see paper 3 and 5 of this compilation.
112 delusions are adopted as the hallmark of psychotic delusions (see also Sass, 1994, Chapter 3 and Ratcliffe, 2013). This is one of the ways in which the adoption of a delusional belief of thought insertion might be characterized as a doxastic hybrid. However, it is not the only way.
It is important to note that there are cases where the alien agent is not present in the patient’s field of awareness at the moment of the adoption of the delusional belief. Here is a way in which a hybrid model might deal with these cases. First, it is important to consider the complexity of our conscious life. While writing this paper, I am not only experiencing certain thoughts (that are the base on which I guide my writing) or just having certain visual experiences; I am also remembering, hearing, smelling, evocating, and so on, all at the same time. However, while just some of these states catch my attention, most of them remain in the background or periphery of my conscious activity. This is what William James calls ‘fringe consciousness’. The mental states that remain in this fringe can be perceptions, thoughts, feelings, memories, etc.
An option here is to say that in trying to make sense of a thought that is experienced as inserted (in a context of experiential confusion), patients explain it picking up randomly some of the elements that have remained in the periphery of their conscious attention or even in their memory. It could be that ‘Chris’ was not part of the main field of awareness; however, Chris might have been available to be retrieved from a thought or a memory from the fringe of consciousness. Thus, the delusional belief would put together these two endorsed components as a delusional explanation in a similar way in which it is done in the first hybrid option just aforementioned. It is important to note that a hybrid model does not need to appeal to a direct perception of the potential alien agent. Rather, it might arise from the many contents available in the fringe of consciousness or memories of the subject. By claiming this, in turn, a hybrid model might be able to link the final delusional report with the patient’s set of background knowledge.
A final promising way of formulating a hybrid model of thought insertion is by appealing to the affordance model of agentive mental attribution sketched in the first paper of this compilation90. On this view, thoughts do not include a full feeling of mental agency. But, at the same time, they are characterised by an affordance of agentive attributability i.e. we experience the possibility to attribute a thought appearing in one’s stream of consciousness to a potential author. In this sense, thoughts would not include explicit representational information about their authors and, from this point of view, the author of a thought (whether myself or external) is always an explanation for certain phenomenally available thought. This model proposes that,
90 See section 5 and 6 of the first paper of this compilation.
113 under certain abnormal circumstances, the affordances of a certain phenomenally available thought might change, and this claim is entirely consistent with all the experiential changes that precede certain paradigmatic cases of psychotic delusions (Conrad, 1958).
Thus, under rarefied conditions, thoughts might afford non-paradigmatic acts because ‘the kinds of possibility that frame one’s experience and thought have changed and nothing presents itself as offering quite what it used to’ (Ratcliffe, 2013, p 238)91. It is not my intention to completely repeat the model here but the main idea is that the affordance model of agentive attributions establishes solid foundations for a hybrid view of thought insertion. When adopting delusions of thought insertion, patients would endorse a thought as being inserted and an affordance of external attributability. Thus, the author of the thought finally referred to in the patient’s report would arise in explaining the different abnormal features of the thought experienced by the patient. In this sense, the final adoption of the delusion would include endorsement and explanationist elements as a part of a single hybrid doxastic state. A hybrid formulation of thought insertion based on the affordance model of attributions of mental agency would involve the claim that by the endorsing a thought with a number of abnormal features, patients would become prone to explain this experiential data using the abnormal affordance as a referential explanatory framework92. Thus, patients would arrive at the various propositional contents of a single complex delusional belief by way of endorsement and explanationist mechanisms working together.
6. Concluding Remarks
According to dominant current approaches, delusions are abnormal beliefs grounded in abnormal experiential states of different kinds. However, the exact role of these states is still the focus of debate within the doxastic approach. In this article, I have formulated this debate in the specific context of the occurrence of delusions of thought insertion. The analysis shows that both the endorsement and explanationist alternatives have different explanatory strengths and weaknesses in explaining the different aspects of our target phenomenon. Thus, it seems plausible to claim that, as Pacherie, Green & Bayne (2006) do, a comprehensive account for
91 Paper 3 of this compilation can be taken as a partial treatment of the affective conditions that might change mental affordances. Paper 5 focuses on the perceptual conditions that might lead to a change in this phenomenal aspect of thoughts. 92 As mentioned in the fist paper of this compilation, psychotic patients tend to exhibit an explanatory bias referred to as ‘jumping to conclusions’ (JTC) (see Bortolotti 2010). JTC is related to a deficit in the evaluation of evidence that might support a certain doxastic hypothesis without having enough evidence for it (see Evans, Averbeck & Furl, 2015). Taking these elements into serious consideration, the endorsement of an affordance of external agentive attributability leading up to the external attribution that characterizes thought insertion might be prompted by the interaction between these cognitive deficits and the role that such an explanation might play in gaining a certain degree of phenomenal unity and organization in the patients’ experience of themselves and the world (see Mishara & Corlett, 2006).
114 delusional phenomena in general might contain both endorsement and explanationist elements. Arguably, the attempt to explain all delusions by using a simple doxastic alternative is far too ambitious and it seems reasonable to suggest that, in some cases, patients might adopt delusional belief by way of endorsement and explanationist mechanisms working conjointly. The proposed idea is that delusions are complex in propositional content and that these two modalities would structure different propositional elements of the final doxastic state reported by patients. Finally, the suggestion is that delusions of thought insertion should be characterised as hybrid delusional beliefs. While the advocates of explanationist views still struggle to account for the doxastic content of the delusions, and endorsement theorists still need to make better sense of the type of experiential states that they posit, the view proposed here seems to overcome these problems. Certainly, all the hybrid formulations sketched in the last section are open to a number of improvements and objections. However, the main aim of this paper has not been to defend a full version of a hybrid model of thought insertion. Rather, it has been to explore some formulations as a way of showing that hybrid models might be on the right track to explain the process of adoption of delusional beliefs overcoming the problems commonly associated with full endorsement and explanationist models. Although further formulation and research in needed, hybrid doxastic models seem to be a plausible way to deal with complex phenomena such as delusions of thought insertion.
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118 Psychosis and The Role of Affective Impairments in the Aetiology of Thought Insertion
Summary
Current dominant approaches to the aetiology of delusions of thought insertion focus on the examination of different deficits that lead to this psychotic phenomenon. However, these approaches seem to have neglected the role that the different impairments in affectivity that patients experience before the adoption of delusional beliefs might play in explaining the psychogenesis of the phenomenon. As a consequence of this, these approaches offer an incomplete picture of it. In this paper, I argue that there are good conceptual and empirical reasons to think that affective impairments play a crucial role in the process of formation of inserted thoughts. After examining two different formulations of the aetiology of delusions, I evaluate one specific view that attempts to integrate the role of affectivity into the aetiological picture of thought insertion and after commenting on some of their most problematic aspects, I propose an alternative deficit account based on Martin & Pacherie’s model of thought formation. Next, I propose a conceptual integration between my proposal and the explanatory structure of the current two-factor view of thought insertion. Finally, I offer some reflections on the practical consequences of my analysis for the treatment of delusions.
A shorter version of this paper has been published in the Review of Philosophy and Psychology as ‘Schizophrenia and The Place of Egodystonic States in the Aetiology of Thought Insertion’. Different sections of this paper were presented at the Heidelberg University Clinic for General Psychiatry ‘Kolloquium der Sektion Phänomenologie’ (Germany), at the ‘Symposium: From mental illness to disorder and diversity’ of the Meeting of The Society for the Study of Artificial Intelligence and Simulation of Behaviour (The University of Kent, United Kingdom), and at the ‘16th Biennial Conference of the International Society for Theoretical Psychology’ (University of Coventry, United Kingdom).
Acknowledges: I would like to thank Prof Dr Thomas Fuchs, Dr Leo Tarasov, Dr Sam Wilkinson, Dr Jennifer Corns, and Dr Roberta Payne for useful comments on earlier drafts of this article.
119 Reason is, and ought only to be the slave of the passions, and can never pretend to any other office than to serve and obey them
David Hume
1. Affective States and Two Stories about the Formation of Delusions
Although there are numerous approaches to explaining the psychogenesis of delusions, a basic distinction is usually drawn between motivational approaches on the one hand, and deficit approaches on the other (Mckay, Langdon & Coltheart, 2009; Bortolotti; 2013; 2014). The former class claims that the production of delusions is motivated by the psychological benefits they confer to the deluded subject (see Bentall & Kaney, 1996; Bell, 2003). Delusional phenomena are characterized as active psychological responses to threatening internal or external psychological stimuli, these responses not being necessarily linked to any particular type of affective, perceptual, or cognitive deficit or malfunction93. In fact, motivated delusions would be the product of mechanisms originally meant to protect the self (see McKay & Dennett, 2009). What makes a certain stimuli especially threatening within this framework is the affective relevance that this stimuli has in the patient’s psychological life. A certain internal or external stimulus P is problematic for a person S if and only if P is affectively relevant to S’s biography. Thus, motivational views claim that delusions arise as a way of dealing with affectively meaningful conflictive stimuli. As Mackay, Langdon and Coltheart (2009) claim about motivational approaches, on this view, delusions are a psychological manoeuvre produced to maintain psychic integrity and decrease the anxiety created by psychologically relevant stimuli. Because of this, it is usually claimed that on this view, delusions have a psychologically adaptive or palliative character (Roberts, 1992; Bortolotti, 2014).
Contrasting with the motivational formulation of delusions, deficit approaches conceptualize delusional phenomena exclusively as the result of different impairments at different stages of the process of belief and thought formation (McKay & Dennett, 2009). Rather than adaptive psychological responses, delusions involve disorders and alterations in the normal functioning of beliefs produced by a combination of anomalous first-order perceptual experiences (Maher, 1974; 2003), impairments in the process of hypothesis evaluation (Langdon & Coltheart, 2000), or unusual experiences accompanied by reasoning biases (Garety et al. 2001), among many others. Contrasting with motivational approaches, the deficit formulation characterizes
93 This seems to be one of the most criticized aspects of the motivational formulation of delusions. See paper 5 of this collection.
120 delusions as intrinsically pathological, namely, as not having any type of palliative or adaptive role in the patient’s psychic life (see Campbell, 1999; Maher, 2003; Coltheart, 2005; among many others)94.
One of the most relevant differences between these two traditions is their emphasis on the role of affective states in the production of delusional phenomena. While affectivity is the most important aspect of human architecture to be considered within motivational formulations of delusions, this aspect of human mental life has received little attention within deficit approaches95. The main idea behind motivational approaches is that such phenomena would play a crucial role in maintaining the mind’s homeostasis96. Affective conflicts would produce a general state of mental unbalance and delusions would be a way to overcome this state. From a motivational standpoint, Roberts (1992) claims that delusional phenomena would allow patients to incorporate highly negative affective experiences within their personal conceptual framework.
In the same line, Butler (2000) claims that delusions might emerge as a meaning-giving strategy, i.e. as an attempt to make sense of a catastrophic loss or feeling of emptiness in the patient. Butler even suggests that some delusions might protect patients from intolerable feelings of depression after traumatic episodes. Finally, Martens (2002) suggests that delusional systems constitute routes to remission. They allow the temporary avoidance of an unbearable affective aspect of the patient’s reality; after the patients’ circumstances become favourable, they are ready for healthy development and remission (p. 503). One of the key aspects of motivational views of delusions is that they aim to make sense of the affective significance or affective meaning that delusional phenomena might have for the patients. The idea is that the affective aspects of delusions reveal some of the most profound links between their phenomenological manifestation and the patients’ background psychology; by making sense of this link, it is possible to understand how certain delusions become psychologically adaptive. Once this connection is clarified in each clinical case therapists would be ready to help patients with their process of recovery (Martens, 2002).
One proposal along these lines is Bentall and colleagues’ model of persecutory delusions (Bentall & Kaney, 1996; Kinderman & Bentall, 1996; 1997). On this motivational approach,
94 For a discussion on this issue, see Paper 5 of this compilation. 95 A possible exception to this is Ellis & Young’s view of Capgras delusions (Ellis & Young, 1990; Stone & Young, 1997). 96 I use ‘homeostasis’ to refer to the mind’s need to reach and maintain a certain state of equilibrium (see, Guidano & Liotti, 1983; Guidano, 1991).
121 persecutory delusions are the result of psychological mechanisms that are aimed at maintaining the patient’s self-esteem when certain events highlight radical discrepancies between negative self-perceptions and self-ideals. On this account, persecutory delusions on this account arise to solve this affective conflict; they are adaptive for the role they play in re-establishing the patient’s mental homeostasis. Another account that relies on the idea of delusions being adaptive is Butler’s (2000) model of ‘Reverse Othello Syndrome’. Butler describes the case of a patient who a year after surviving a severe car crash, became convinced that he and his former partner – who had left him at that time – were, at that moment, happily married. The patient repeatedly tried to persuade people that his ex-partner was still sexually involved with him. Butler (2000) suggests that the delusion was not explicable by any organic pathology – not even by the patient’s head injury – so the delusion likely emerged as a way of dealing with ‘the stark reality of annihilating loss’ (p. 89). The delusional belief provided the patient a deliverance from an affectively intolerable episode in his life97.
One of the advantages of motivational accounts is that they can plausibly link the manifestation of certain delusions to some of the patients’ most significant affective themes over time and, by doing so, to contribute in a number of ways to the psychotherapeutic treatment of delusions. For example, this link allows therapists to make sense of delusions from a diachronic point of view and therefore to elaborate more specific and efficient interventions, based on the patients’ own psychological resources and biography98 (see Kinderman & Bentall, 1996). In addition, the understanding of the affective significance of delusions might allow therapists to understand the context and some of the external causes of the occurrence of certain delusions. In turn, this would allow therapists to elaborate different strategies for patients to cope with their delusions under certain circumstances (see Guidano, 1991).
Now, the most prominent versions of the deficit approach to delusions is the two-factor view – TFV henceforth – which claims that delusions are rooted in anomalous experiences resulting from different impairments in the process of belief production (factor 1). However, the presence of the anomalous experience is not itself sufficient for the formation of a delusion (Davies, Coltheart, Langdon & Breen, 2001). In contrast with one-factor views – another popular deficit approach where delusions are seen as reasonable hypotheses given the strange character
97 One of the weaknesses of Butler’s position is that its primary interest is with a very specific and rare delusion. Therefore, it is not entirely clear if his conclusions can be extrapolated to the analysis of other delusions. 98 It is widely granted among psychotherapists that a good quality psychotherapeutic intervention should use the patient’s own psychological resources and biographically relevant elements for the intervention to be meaningful (see Guidano, 1991; Arciero & Bondolfi, 2011).
122 of the abnormal first-order experience (Maher, 1974) – the TFV proposes a deficit in the system of belief evaluation (factor 2) to explain the routes from some abnormal experiences to certain delusions. Thus, by the introduction of a second factor involved in delusion formation, the TFV overcomes the difficulty that one-factor views have in explaining why there are people with experiential impairments that do not develop delusional beliefs (Langdon & Coltheart, 2000). One of the main merits of deficit approaches is that they are strongly supported by empirical data (Coltheart, Langdon & McKay, 2007). For example, according to Hirstein and Ramachandran (1997), Capgras patients fail to show a pattern of automatic discrimination when showed pictures of familiar and unfamiliar faces while control subjects show a higher automatic response to familiar faces. More recently, Martin and Pacherie (2013) have suggested that schizophrenic patients reporting thought insertion fail to integrate causal information about the occurrence of certain thoughts as a result of different impairments in attention and working memory.
Both motivational and deficit approaches have their own merits. While motivational approaches are able to capture the significance of certain delusions in the patients’ psychic life, deficit approaches put forward empirically well-supported explanations of delusions. Over the years, these two classes of explanation have developed separately and, most of the time, they have been characterized as incompatible by several authors (Ramachandran, 1995; Stone & Young, 1997; Ramachandran & Blakeslee, 1998). With a few exceptions, this conceptual isolation has led psychiatrists and philosophers to miss the possibility of a conceptual integration between some of the ideas coming from these two different traditions. The main purpose of this paper is to elaborate an alternative way of making sense between the relationship between affectivity and the process of production of delusions within a deficit framework in the specific context of the debate about the aetiology of thought insertion, one of the more complex symptoms of psychiatric disorders.
In making sense of delusions, motivational approaches have consistently integrated the role that affectivity – specifically, affective conflicts – might play in giving rise to psychotic phenomena. However, this issue has been neglected by deficit approaches to thought insertion and, as a consequence of this, they offer an incomplete aetiological picture of the phenomenon. After clarifying the main subjective features of thought insertion, I claim that there are sufficient empirical and conceptual reasons to think of affective states as a crucial doxastic force in the process of formation of delusions of thought insertion and therefore reasons to think that impaired affectivity plays an important role in this process. I examine one specific view that integrates the role of affectivity into the psychogenesis of thought insertion and after
123 commenting on some of its most problematic aspects, I propose an alternative deficit view based on Martin and Pacherie’s (2013) model of thought formation. Next, I propose a conceptual integration between my proposal and the current two-factor view of thought insertion. Finally, I offer some reflections on the consequences of my analysis for the treatment of delusions.
2. Thought Insertion: Main Subjective Features
Thought insertion is claimed to be one of the most severe – although not exclusive – symptoms of schizophrenia (Mullins & Spence, 2003). From a first-personal point of view, people suffering from thought insertion report that certain thoughts or ideas are placed into their minds by external agents such as persons (e.g. TV celebrities, relatives; see Frith, 1992), electronic devices (e.g. TVs, radios; see Spence et al. 1997), collective groups (e.g. aliens, the government, secrets societies; see Payne, 2013), or surrounding inanimate entities (e.g. houses, trees; see Saks, 2007), among many others. Based on the main patients’ reports available in the literature, a plausible account of the phenomenon should be able to make sense of the following set of features99:
(i) Lack of sense of ownership: Normally, thinking is experienced as an activity that is being carried on by oneself. There is a quality of ‘ownership’ or ‘mineness’ attached to cognitive activity. However, as Fish (1962, p. 48) suggests: ‘in schizophrenia this sense of the possession of one’s thoughts may be impaired and the patient may suffer from alienation of thought […] [the patient] is certain that alien thoughts have been inserted in his mind’100. Lately, Billon (2013) and Billon & Kriegel (2015) claim that the alien thought in question should not be characterized only in terms of the phenomenal features it lacks. The authors suggest that apart from this reported lack of ownership, these patients experience the relevant thoughts as inserted. In this sense, the feature of ‘being inserted’ instantiate in the reports would not be part of an explanation offered for the occurrence of thoughts with bizarre phenomenal features. Rather, it would be part of the way alien thoughts are phenomenologically given.
(ii) External Attribution: Patients identify the agent that is claimed to be inserting the alien thought into their minds. For example, a patient claimed that Eammon Andrews’ thoughts were flashed into her mind (Mellor, 1970, p. 17). The contents of the inserted thoughts are as diverse as the type of external agents identified by patients in their reports. For example, a patient reports that a set of specific rules was inserted into her mind by aliens (Payne, 2013, p. 152), while
99 For a more complete description of these features, see the introduction of this compilation. 100 In this paper I will remain silent about the discussion of the nature of this property. For further discussions on this issue, see paper 1 and 2 of this compilation.
124 another has referred to artefacts such as a television and a radio as responsible for electrically inserting thoughts into her mind (Spence et al., 1997).
(iii) Selectivity of alien thoughts: Inserted thoughts can be claimed to be selective in two senses. First, in experiencing an alien thought, there are other simultaneous or subsequent mental states that are not experienced as inserted (Gallagher, 2004). For example, patients experience a sense of realization that a certain thought is inserted and this sense is not itself inserted (selectivity type 1). Second, in psychosis, patients experience only a certain type of mental states as alien i.e. feelings, emotions, thoughts, and impulses (selectivity type 2).
(iv) Specificity of alien thoughts: Gallagher (2004) claims that only a certain specific kind of mental content is experienced as alien by patients. Alien thoughts are, most of the time, associated with significant others or with themes that are affectively relevant to the patients.
(v) Sense of permeability of ego-boundaries: Our mental life is characterized by a phenomenological demarcation between ‘me’ and ‘not-me’ (Parnas & Handest, 2003). This sense of ego-boundaries creates a robust sense of private access to our own experiences. However, the sense of ego-boundaries is blurred in cases of thought insertion as patients experience an external agent placing thoughts into their stream of consciousness. As Freud (1930, p. 13) noted: ‘There are cases in which part of a person’s own body, even portions of his mental life - his perceptions, thoughts, and feeling- appear alien to him and as not belonging to his own ego’.
(vi) Absence of a Sense of Causal Coherence: A feeling of causal coherence emerges when information concerning the triggering aspects of a certain thought is integrated into the occurrence of the thought (Martin & Pacherie, 2013). Causally integrated thoughts are experienced as ‘coherent and unified episodes of thinking’ (115), and have a specific ‘phenomenology of coherence’ (116). In contrast, inserted thoughts are first-personally experienced as ‘decontextualized’ or coming ‘out of nowhere’.
3. Impairments in Affectivity and the Formation of Delusions
With a few exceptions, deficit approaches have generally taken affective impairments in the context of psychosis as a mere consequence of the stress and anxiety associated to the occurrence of delusional phenomena. Sometimes, affective states have been understood as elusive mental states better reduced to either cognition or volition, or simply ignored as mere
125 epiphenomena (Berrios, 1985; Guidano, 1991). However, although it is true that affectivity – and more specifically, affective performance – is affected by the stress associated with delusional phenomena (post-delusional affective impairments), there seems to exist sufficient empirical evidence to suggest that anomalous affective states are a crucial doxastic force involved in the psychogenesis of inserted thoughts (pre-delusional affective impairments). So to speak, impaired affectivity is ‘already there’ when delusional beliefs are adopted. A complete picture of our target phenomenon should be able to integrate this evidence into its aetiological picture.
When talking about affectivity, there is a preliminary conceptual issue in need of some clarification. It is not easy to define what an affective state is. As noted by Fuchs (2013), affective states vary between short-lived, intense, object-related states and longer lasting, objectless states remaining in the background of awareness. Here, I shall define affective states as those states that involve a certain – positive or negative – valence for a subject and that make her act in a certain way. The nature of such acts can be behavioural (e.g. crying, running, and so on) or cognitive (e.g. seeking for explanations, wondering, etc.). ‘Valence’ can be defined as the attractiveness (positive valence) or aversiveness (negative valence) that a certain situation, event, physical object, bodily sensation, or person has for the individual undergoing that state (Fridja, 1986). Based on their significance for the subject undergoing such states, affective states can be egosyntonic or egodystonic. The former class consists of those states that are in agreement with the needs, self-image, expectations, and goals of a subject, whilst the latter class consists of those states that are not in harmony with the subject’s background psychology. It is important to note that different types of mental states -such as beliefs, thoughts, desires, perceptions, and so on- can become affectivity-laden when experienced as conflicting, aversive, or unpleasant. While the belief that it is raining outside can remain affectively neutral, the belief that one’s mum does not love one can become affectivity-laden in virtue of its affective significance for the person holding that belief (assuming that maternal love is important for this person).
Important in this context is the fact that the relationship between affective and affectivity-laden states in the context of the aetiology of thought insertion has remained mostly unexplored. This is because deficit accounts normally consider affective and affectivity-laden states as secondary in importance in the general process of formation of delusions (Guidano 1991; Skodlar et al. 2012; Maiese, 2014). However, affectivity in a psychotic context has been shown to be impaired in a number of different dimensions, such as mood instability, enhanced negative reactivity, emotion regulation strategies, and baseline affective negativity (Henry et al. 2008; Marwaha at al. 2013; Kramer et al. 2013; Strauss et al. 2013). All of these disturbed
126 dimensions might play a role in triggering and constraining the formation of abnormal thoughts under pathological conditions (see O’Driscoll, Laing & Mason, 2014).
In the same light, Strauss et al. (2013) suggest that pre-psychotic affective instability might shape the occurrence of psychotic symptoms. Buckley at al. (2009) and Van Rossum et al. (2011) report that schizophrenic delusions often arise in a general context of negative affectivity. In addition, it is reported that patients that later go on to develop psychotic symptoms present a high susceptibility to mood instability in pre-psychotic stages. Broome et al. (2005) and Broome et al. (2012) report high rates of anxiety and depressive states among people at risk of psychosis prior to the occurrence of the relevant psychotic symptoms. Interestingly, this reported vulnerability to psychosis produced by anxious and depressive moods seems to involve an increased hypothalamic pituitary axis response to stress (Aiello et al. 2012), which in turn would increase the patients’ general reactivity to negative stimuli such as egodystonic states. In the same line, Kramer et al. (2013) suggest that this enhanced reactivity may produce a general state of affective instability in the patient that, in turn, may lead to the development of certain psychotic symptoms.
The strongest support for the idea of abnormal affective states playing a crucial role in the aetiology of delusions of thought insertion is provided by Marwaha et al.’s (2013) analysis of two British national surveys of psychiatric morbidity. The authors report a strong link between mood instability and psychotic symptoms, suggesting that mood instability may predict the emergence and maintenance over time of certain delusions (p. 6). More specifically, Marwaha et al. (2013, p. 6) claim that ‘the sense that emotional experiences are out of one’s personal control may prompt a search for meaning that may find explanations in terms of external influence’, which would be consistent with the standard characterization of thought insertion (section 1). All of this evidence calls a reconsideration of the role that certain affective impairments might have in the aetiology of delusions in general, and thought insertion in particular.
Certainly, by neglecting the exploration of the impaired dimensions of affectivity and their relevance for the process of formation of delusions, deficit accounts seem to have arrived at an incomplete understanding of, among others, delusions of thought insertion. There seems to be sufficient empirical evidence to suggest that affective states might be an important doxastic force in the process of formation of delusions. Therefore, alternative approaches are needed in this context. This is important for two main reasons: first, the inclusion of affectivity impairments into the deficit picture of thought insertion would certainly contribute to a more complete an
127 empirically better-supported understanding of the phenomenon; second, the consideration of the affective context in which certain delusions are produced would allow deficit approaches to inform the development of more focused psychotherapeutic technics in the treatment of delusions. In the following section, I analyse the problems and merits of one of the alternative accounts that integrates affective states into the task of explaining the psychogenesis of thought insertion. This analysis will open the door to the clarification of the role of affective states in the aetiology of thought insertion, and the analysis of some of the theoretical implications of this idea.
4. Affective Routes to Delusions: Thought Insertion as Thought Aversion
It is usually granted that there can be affective routes to certain beliefs (see Davies, 2008; Pacherie, 2008). As Bayne and Pacherie (2004, p. 7) suggest: ‘[in some cases] beliefs can be generated and maintained by the emotional functions they serve’. This issue becomes clear in, for instance, cases of self-deceptive beliefs:
Sonia has cancer, and has been told by doctors that she has months to live. She avoids talking about the diagnosis, and continues to live as though her illness is merely temporary. She is saving money for a trip to see her son in 1 year, and she refuses to put her affairs in order despite the requests of her friends and family to do so (Bayne & Fernández, 2009, p. 2).
In this case, it seems that the painful nature of Sonia’s experience makes her form and maintain the self-deceptive belief that she has no illness. The self-deceptive belief seems to emerge as a way of dealing with a painful aspect of Sonia’s psychological reality. However, this does not necessarily imply that the formation of that belief is not rooted in a deficit in the process of belief formation (Bayne & Fernandez, 2009). In contrast, the link between affective states and the formation of delusions is less clear and, apparently, has not been sufficiently investigated in the context of the understanding of the aetiology of delusions of thought insertion. As pointed out by McKay, Langdon & Coltheart (2009), one of the main insights attributed to motivational approaches is that affective states might have access to the process of belief and thought production and therefore they might play an important doxastic role in the aetiology of certain delusions, such as thought insertion. Current deficit approaches to thought insertion seem to have neglected this insight. Perhaps, this explains why these approaches have not yet included the different impairments in affectivity preceding the adoption of delusional beliefs in the aetiological picture of thought insertion.
128 One of the models that try to integrate affectivity into the discussion regarding the aetiology of inserted thoughts is the thought-aversion hypothesis (TAH henceforth)101. The TAH is a motivational view attributed to Snyder (1974) and it explains the dissociation characterizing thought insertion as the result of an underlying affective conflict which causes the subject to externalize a problematic thought. The hypothesis can be stated as follows:
TAH: A subject fails to acknowledge a certain thought as her own and attributes it to an external agent due to her negative evaluative attitude towards the thought’s content (Snyder, 1974; cf. Graham & Stephens, 1994, p. 103).
The TAH explains the occurrence of inserted thoughts in two stages: (i) patients negatively evaluate a thought, leading to feelings of aversion towards that thought. It is not clear whether this process is completely unconscious, or part of the conscious content of inserted thoughts. (ii) These negative feelings motivate the subject to dissociate and explain the occurrence of such thought in terms of external agency102. Finally, the externalization of the thought allows the patient to deny responsibility for this originally ‘unbearable mental state’ (Snyder, 1974, p. 121). According to Gibbs (2000):
If a thought to which one attaches negatives attitudes appears in one’s stream of consciousness, one option for the subject is to attribute the thought to someone else. For instance, if the thought “I want to kill my daughter” runs willy-nilly through a loving mother’s mind, she might be so disgusted by the thought that she is compelled to disown it (198).
The assumption here is that what is aversive about the thought is its content. This aversive content then triggers explanations in terms of alien agency leading to the conscious experience of thought insertion. As such, the TAH seems to offer an explanationist model of the phenomenon. Explanationist models suggest that delusional beliefs reflect an attempt to explain highly unusual experiences via rationalization or abductive inference (see Ellis & Young, 1990; Coltheart, 2005; Synofzik, Vosgerau & Newen, 2008)103. According to the TAH, patients infer from the initial aversive content of the thought that it is someone else’s; the external attribution arises as a second
101 This model seems not to be very popular in the philosophical literature on thought insertion. However, it does seem to be quite popular among psychotherapists and practitioners, especially between those trained in the psychoanalytic tradition. 102 Interestingly, this idea seems to be consistent with what is claimed by Marwaha et al.’s study (2013) on the empirical evidence that links affective disruptions with the psychogenesis of delusions. 103 Contrasting with explanationist models, endorsement models suggest that delusions are the result of patients doxastically endorsing the content of their unusual experience (Sollberger, 2014). For a discussion on this issue, see paper 2 of this compilation.
129 order explanatory move, based on the subject’s need to give meaning to the abnormal first order affectively relevant experience104.
A way of assessing the TAH’s plausibility is by examining if it is able to explain the most characteristic features of thought insertion (see section 1). It seems that according to the TAH the aversive feelings produced by the negative evaluation of a thought lead a patient to deny ownership of the relevant thought. This might suggest that the evaluation of the thought is an unconscious process that allows the conscious experience of a disowned thought. However, the patient still experiences the external thought as agential and, because of this, she might explain its occurrence as the product of someone or something else’s agency. The role of the external attribution is to find an agent responsible for the occurrence of the intrusive thought. This aspect is crucial to understanding the adaptive role of the delusion in the patient’s psychological life. In line with what is suggested by most motivational accounts (see Section 1), thought insertion would constitute a way of recontextualizing and incorporating a highly disruptive thought (as a case of cognitive experience) within the patient’s conceptual framework and therefore a way of restoring the patient’s psychological homeostasis.
Prima facie, the TAH offers a plausible explanation of the specificity and selectivity of inserted thoughts. Following the TAH, contents that are externalized are always those that are dystonic with the patient’s background psychology. Certain thoughts are externalized in virtue of their meaning for the patient’s psychological life. On this view, aversion seems to be a sufficient condition for a thought to be externalized. It is crucial to note that aversion always depends on the patient’s set of personal representations about reality and herself. What is aversive for one person is not necessarily aversive for another. Therefore, aversion always reflects some of the patient’s affectively relevant personal themes (Gibbs, 2000).
According to the TAH, the thought with aversive character is that which is experienced as alien. The aversive character of the thought is what distinguishes itself from the rest of the non-externalized mental states that are simultaneously occurring in the patient’s stream of consciousness. This suggestion seems consistent with Pickard’s (2010) claim about the selective nature of inserted mental states, namely, that they represent a manifestation of the patient’s background psychology. Although the TAH does not explicitly aim to explain these features, we can hypothesize that the lack of a sense of causal coherence in experiences of thought insertion
104 There are some similarities between this idea and what has been more recently proposed by Coltheart (2005) and Synofnik, Vosgerau and Newen (2008).
130 arises as an experiential consequence of the first-order lack of a sense of ownership that patients feel toward the aversive thought. A second option is to say that the lack of a sense of causal coherence is simultaneously given with the lack of ownership characterizing the inserted thought105. Finally, the sense of permeability of the patient’s ego-boundaries can be understood as an experiential consequence of the external attribution that patients make in order to recontextualize and integrate the aversive thought.
At this point, it should be clear that the TAH attributes to thought insertion a psychologically palliative role; through the motivated externalization of the aversive thought, patients are able to overcome an originally unbearable cognitive stimulus. Just like Bentall’s and Butler’s models, the TAH is able to link the phenomenological manifestation of thought insertion to the patient’s background psychology in a plausible way. This is because the unbearable nature of a certain stimulus always depends on the patient’s affectively relevant themes. Finally, by doing this, the TAH is able to account for the meaning that delusions of thought insertion might have for the patient’s psychological life. Consequently, the TAH can incorporate all the psychotherapeutic advantages commonly associated to motivational approaches.
5. The Thought Aversion Hypothesis under Examination
In developing their own deficit account, Graham and Stephens (1994) claim that the TAH is not supported by clinical data. Assuming that the aversive character of the delusion is instantiated exclusively by its content, the authors claim that the first-order stimulus that underlies the formation of inserted thoughts does not always have a negative character (p. 104). From this, the authors conclude that the delusion is not necessarily the result of thought aversion and that we should rule out the type of explanation offered by the TAH106. Graham and Stephens appeal to related symptoms of schizophrenia to make their case; they suggest that studies of verbal hallucinations in schizophrenia show that, while comments made by ‘voices’ are often persecutory or demeaning, they sometimes encourage or console the subject. They also emphasize the fact that voices can be innocuous and that often they offer neutral comments or advice (Graham & Stephens, 1994, p. 104). For example, the authors describe the case of a young woman who persistently heard the voices of her dead father and her paternal grandmother advising her on different decisions (such as whether to buy a car). The authors note that the
105 In fact, as pointed out in the introduction of this collection, one of the current open questions about the nature of the sense of causal coherence is whether it is something different from the sense of mineness that can accompany conscious thinking in non-pathological situations or if they are one and the same (Seeger, 2013). 106 This conclusion seems too strong since one might say that in some cases thought insertion might be explained as a case of thought aversion while in some other it might not.
131 patient experienced these voices as well-intentioned and as actually helpful to her. They interpret this as a counterexample to the TAH (p. 104).
However, there are several ways of replying to these objections. Graham and Stephens, in their main criticisms of the TAH, appeal to the type of delusive content manifested in auditory hallucinations rather than the content manifested in cases of delusions of thought insertion. Although comparisons between similar phenomena are usually helpful in psychopathology, it is not entirely clear that the authors can rule out the TAH on this basis. Despite some commonalities (inserted thoughts and auditory hallucinations can sometimes manifest themselves as a part of the same delusive episode), they seem to be phenomenologically distinguishable one from the other. For their objection to work, Graham and Stephens need to assume that experiences of inserted thoughts and alien voices have a similar phenomenological quality. However, we should not conflate these two phenomena. Nayani and David (1996, p. 186) claim that some patients suffering from thought insertion report alien thoughts as ‘bad impulses’, and Caponi (2010) reports a case as a ‘voice without sound’, nothing like ‘hearing voices’. A patient also reports that: ‘I didn’t hear these words as literal sounds, as though the houses were talking and I was hearing them; instead, the words just came into my head – they were ideas I was having’ (Saks 2007, p. 27). These descriptions are considerably different from the ones characterizing auditory hallucinations. As Gibbs (2000, p. 196) rightly points out:
The [phenomenological] peculiarity of thought insertion is that the thoughts are readily admitted to occur within the psychological boundaries of the subject, yet she denies that the thoughts belong to her; they are literally perceived as being inserted into the subject’s stream of consciousness, not simply heard from an external source like an auditory hallucination.
One of the main differences between auditory hallucinations and inserted thoughts seems to be represented by the non-sensory nature of the latter in contrast to the sensory – but not veridical – nature of the former. Voices can be bodily felt in a way that thoughts cannot. In fact, the same patient can report inserted thoughts and auditory hallucinations as part of the same psychotic episodes and it seems plausible to claim that the patient can distinguish between these two phenomena in virtue of their sensory differences. These two symptoms seem to constitute two different phenomena and it is not clear if Graham and Stephens can use the cases of one to
132 rule out a hypothesis meant to explain the other107. Now, it can be argued that in some cases, thinking acquires some sense-like features. Sometimes, thoughts are felt as streaming away through some body parts (Kusters, 2014). Some other times, patients feel thoughts entering into their head and they can pinpoint the exact place of entry (Cahill & Frith, 1996). However, the relevant difference remains. In all these cases, thoughts are no referred with the same quality as voices so even if they acquire some sense-like phenomenological features, they are not the required to consider thought insertion not clearly distinguishable from auditory hallucinations.
It seems plausible to think that the type of content manifested in thought insertion is not necessarily the same type that would be manifested in verbal hallucination. The type of delusive content might result from a particular aetiological route to a particular type of pathological experience. Different pathological phenomenologies might have different aetiologies, and different aetiologies might manifest different types of delusional contents. In light of this, we can see that the comparison posited by Graham & Stephens conflates two different phenomena without offering any justification for this. So, unless the authors establish a better – phenomenologically and methodologically – justified link between these phenomena, we should not take cases of alien voices as providing evidence against the TAH (see Gibbs, 2000, pp. 197- 198).
Graham and Stephens (1994, p. 104) claim that ‘the clinical literature does not support the notion that the subject’s failure to acknowledge her alien thought as her own is necessarily motivated by her disapproval of the intentional states they [the thoughts] seem to express’. However, this claim is problematic in a number of ways and it seems to be based on an unfair treatment of the TAH. The authors have certainly not presented any cases of ‘encouraging’ or ‘supportive’ inserted thoughts108. However, even if there were such cases, they would represent a
107 A possible reply to this point is that the hypothesis might be applicable to both phenomena. However, this reply assumes that there are no important phenomenological differences to be explained between thought insertion and alien voices, which is exactly the point at issue. 108 An objection to this point might be to say that in some non-Western cultures, some episodes that might be described as thought insertion are experienced with a positive character (see for example, Bentall; 2003). However, first, it is not obvious that these experiences can be regarded as cases of thought insertion for it is not clear that they posses the subjective features commonly attributed to this delusion. Second and more important, it is not clear that these cases can be regarded as delusional at all. Psychiatric diagnostic is culturally-dependent and what is delusional in one culture might not be in a different one, which is key in the debate about the negative character of delusions (Gaete, 2008). If we take one of the most basic - but not unproblematic - notions of delusions, i.e. ‘a false belief based on incorrect inference about external reality that is held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary’ (American Psychiatric Association, 2013, p. 819), one might say that these subjects are experiencing culturally accepted beliefs (e.g. having a guardian angel that inserts thought into your mind) and therefore, these experiences would not be delusional. In turn, this might explain why these subjects do not undergo such experience accompanied with a negative character. Even if these beliefs are false, they are not themselves delusional in those cultures. As Gilleen & Davies (2005, pp. 5-6) suggest: ‘Delusions are generally
133 minority of cases. Strauss et al. (2013) explain that schizophrenic delusions are usually characterized by stress and negative affective significance (see also Sass, 1992, p. 231; Smith, 1982, p. 30; Fish, 1984; Saks, 2007). Along the same line, Gibbs (2000, p. 2000) claims that: ‘most commonly, [inserted thoughts] take the form of commands, mocking or criticizing thoughts’. So, even if the authors insist that thought insertion is not necessarily a result of a subject’s disapproval of the content of a thought and that, therefore, alternative explanations are needed, an alternative explanation that cannot make sense of the common negative nature of inserted thoughts would be as incomplete as Graham and Stephens claim the TAH is.
In conclusion to this section, we can say that although they posit a number of interesting issues, Graham and Stephens’ objections to the TAH do not offer plausible reasons to rule out the idea that affective and affectivity-laden states are importantly involved in the aetiology of thought insertion. In the next section, we take seriously the suggestion that these states are an important part of the psychogenesis of thought insertion and develop a tentative proposal that integrates affective and affectivity-laden states into an understanding of this process through the role they play in the general process of thought formation.
6. The Place of Egodystonic States in the Aetiology of Thought Insertion: A Proposal
The existence of different replies to the objections posited by Graham and Stephens does not imply that the TAH is free from other problems. In fact, I think the TAH is importantly incomplete. This hypothesis seems to be unable to clarify the pathological route from aversion to external attribution. The TAH treats aversion as a sufficient condition for a person to externalize a certain thought or, in other words, the TAH explains the alienness of the thought on the basis of its negative character. Bearing some resemblance to the explanatory structure of one-factor theories of delusions, the TAH conceptualizes the external attribution that characterizes inserted thoughts as a strategy motivated by the highly aversive nature of the first-order thought. Problematically, this does not explain the fact that subjects can experience different types of aversive thoughts without developing delusional beliefs about them. This is what makes subjective moral conflicts intelligible, for example; everyone deals with immoral thoughts in everyday life and it is clear that one can experience a highly aversive immoral thought without
accepted to be beliefs which (a) are held with great conviction; (b) defy rational counter-argument; (c) and would be dismissed as false or bizarre by members of the same socio-cultural group’. The present objection does not satisfy (c); perhaps, when had in our culture, such experiences might have a negative character since they are not culturally accepted (or even intelligible).
134 explaining its occurrence in terms of external agency. In fact, it seems that one of the main features of immoral thoughts is their aversive nature. In the same way, the TAH seems not to be able to distinguish between pathological obsessive thoughts – most of the time, they are egodystonic and aversive in nature – and inserted thoughts. For example, the TAH cannot explain why obsessive thoughts in Obsessive Compulsive Disorder (OCD henceforth) are aversive but non delusional in nature. In other words, TAH cannot explain why some aversive thoughts are externalized while others are not.
We are left with a dilemma: on the one hand, current deficit approaches to thought insertion have not been able to integrate the empirical evidence pointing towards the role that abnormal affectivity would play in the aetiology of the phenomenon; therefore, they are importantly incomplete. On the other hand, the approach that attempts to integrate affectivity into the explanation of thought insertion – the TAH – has a number of problems. Taking all of this into consideration, let me here explore an alternative suggestion that overcomes these issues while retaining the intuitive core of the TAH, i.e. that affectivity can be crucial in the process of formation of inserted thoughts.
Graham and Stephens found the TAH implausible because they take themselves to have shown that not all cases of thought insertion are necessarily the result of aversive feelings attached to a certain thought-content. By appealing to the case of a woman hearing her father and grandmother’s voices giving advice, the authors conclude that cases of thought insertion cannot be explained as the result of thought aversion, for in this case no aversive element is identified. As already suggested, this is a case of auditory hallucination and it is not clear that it constitutes a valid counterexample to the TAH (see section 4). In addition, all this shows is that the TAH is incomplete. However, for the sake of the discussion, let me treat it as if it were a case of thought insertion. Suppose that the woman in question suddenly experiences the thought ‘Buy this car! Buy this car! Buy the beautiful one!’, which is finally attributed to her deceased father. My claim here is that the TAH and the current deficit approach to thought insertion cannot grasp the role of affectivity-laden states in the aetiology of the phenomenon, for they rely on an oversimplified understanding of the process of the formation of thoughts and its relationship to affectivity.
According to Gibbs (2000, p. 199), although the thought-content reported by the young woman is not threatening or egodystonic in this case, certain mental baggage leading up to it might be. The idea is that while the thought ‘Buy this car! Buy this car! Buy the beautiful one!’ has no negative character itself, other surrounding factors related to the occurrence of the thought
135 may have such character. Gibbs (2000, p. 199) suggests that, ‘it may be that she has an aversion to making her own decisions’ and consequently, the character of the thought inserted by her father is explicable as the result of the woman’s aversion to a certain situational factor (decision- making). The problem in this context is that both the TAH and Graham & Stephens’ rejection of the TAH assume that the aversive character of inserted thoughts is exclusively instantiated by the externalized thought-content that is expressed in the patients’ reports. Apparently, the TAH and Graham and Stephens’ view endorse an oversimplified and incomplete view of the role that affective states can play in the process of thought formation. In light of this, a broader understanding of the process of thought formation is needed to grasp the role that affective impairments might play in the phenomenon.
Egodystonic states might be important doxastic forces in the process of forming delusions of thought insertion. Thinking is a complex phenomenon and the conscious manifestation of a thought-content is just one part of a complicated process. Martin and Pacherie (2013) have recently suggested that a number of factors can trigger or modulate the phenomenological manifestation of a thought-content. The idea is that when one experiences a thought, one does not only have access to its content, but also to surrounding triggering information, ‘although this information may sometimes be difficult or even impossible to retrieve’ (p. 115). The authors make a basic distinction between internal and external factors that can produce thoughts. The former class consists of the many events and specific stimuli in the outside world that trigger thoughts. For example, if I am sat on the bus and I realise that the person next to me is listening to Justin Bieber (through my auditory experience of such awful melody) might trigger the thought: ‘there is yet another person who lacks good musical taste’ (externally-driven thought). On the other hand, internally driven thoughts are those produced by our own internal cognitive activity. Martin and Pacherie (2013) refer to ‘thought association’ as an example of this type of thoughts. For example, suppose that I have the thought p: that I am going to cook sweet corn pie. This can trigger some other thoughts q; for example, that I need to get some meat and a nice bottle of cabernet sauvignon which, in turn, can trigger further thoughts and so on. In this case, p was triggered by my thinking that q (internally-driven thought).
The authors also identify a number of further factors that modulate and constrain the process of thought formation:
(i) Perceptual constraint: Current perceptual dispositions can affect the process of thought-formation. For example, wearing a beanie that covers my ears while sat next to
136 the girl listening to some music at a high volume might trigger the thought ‘Is that Justin Bieber or a dying cat?’ (ii) Situational constraint: A certain situation can trigger a certain thought. For example, listening a Justin Bieber’s song coming from my flatmate’s room might trigger the thought ‘What on earth is happening there!’ (iii) Doxastic background constraint: The idea is that our thoughts are generated within a personal background of beliefs and knowledge. For example, the thought ‘What on earth is happening there!’ (referring to Bieber’s song coming from my flatmate’s room) is based on my knowledge of my flatmate’s musical taste and my belief that he has quite a good musical taste. Without this knowledge and belief, the produced thought would have been different. As Martin and Pacherie (2013) suggest, ‘the set of possible thoughts your system can produce is a function of your knowledge and set of beliefs’ (p. 116). (iv) Immediate internal constraint: The idea is that a particular thought depends on the thought(s) that precede it. For example, our thoughts about external or internal events may differ if preceded by different thoughts. At a certain moment I might think ‘What is wrong with current pop-music?’. The sudden auditory experience of Bieber’s song might trigger the thought ‘What a coincidence!’. However, if before listening to Bieber’s song, I was thinking something different, the musical melody could have triggered a different thought. (v) Memory constraint: The idea is that a thought about a certain specific stimulus or event depends on our particular set of memories. The thought ‘What on earth is happening there!’ can be based on the set of memories I have of the music my flatmate usually listens to. (vi) Volitional constraint: When having a thought, we have the option to reject it based on a process of thought evaluation. Subjects can exert control over their thoughts and decide whether to go on with it or not. For example, I can be reading in my room. When I listen to Bieber’s song coming from the room next door I can start thinking about music, pop- stars, and so on. However, the authors suggest that by exerting meta-control over my thought I may be able to supress them and go back to my reading. This issue might refer to the ability that subjects have to focus their attention on a certain thought (or set of thoughts) for they are related to the main ongoing task they are undergoing.
Finally, and quite importantly for our analysis, Martin and Pacherie (2013) propose the following constraint:
137 (vii) Emotional constraints: The idea is that our current affective states can influence the content of our thoughts. For example, I can feel anger and this state can trigger or constrain certain thought-contents.
The key problem with the TAH and Graham and Stephens’s position is that they do not consider these factors in their understanding of thought formation, confining affectivity only to its direct relationship with the delusional thought-content. In contrast, Martin and Pacherie’s model would allow the suggestion that egodystonicity might not only be a property associated with the manifested content of a thought, but that it might also influence early stages of the formation of thoughts; certain thought-contents might have an egodystonic formation route under certain circumstances. Therefore, although the delusive content of inserted thoughts sometimes itself has no explicit egodystonic character, its triggering and constraining factors may have it. Note that by including these factors into the picture of how thoughts come about, Martin and Pacherie (2013) offer a broader understanding of the nature of thinking and make plausible the idea that impairments in affectivity might play a role in the psychogenesis of inserted thoughts.
Martin and Pacherie’s model makes an important contribution to the discussion of the integration of the role of affective states into the aetiological picture of thought insertion, and it can be refined in light of current evidence of disrupted affectivity in psychosis (section 2.2.). It seems plausible that the scope of the effects of affectivity impairments in the psychogenesis of thought insertion might go beyond a mere enhanced emotional constraint, because none of the other constraining factors identified by Martin and Pacherie are totally independent of affectivity. It is not just that our current negative affective states can influence the formation of the content of our thoughts but rather, that each one of the triggering and constraining factors described by the authors can acquire a specific affective valence and therefore they can become egodystonic under certain circumstances. In other words, each one of these factors can be affected by disrupted affectivity. As noted earlier, different mental states, such as beliefs, desires, perceptions, among many others, can become egodystonic in virtue of their valence for the subject. Thus, enhanced baseline negative affectivity in pre-psychotic stages might play a crucial role in the structuring of delusional thoughts (Marwaha et al. 2013). Negative affectivity might colour the general experience of the patient’s reality and, in virtue of this, might influence the way in which all triggering factors are integrated into the causal occurrence of a thought. In the context of general impaired affectivity, perceptual, situational, doxastic, immediate internal, memory, and volitional constraints might get coloured by an egodystonic significance, negative affectivity acting as the framework of meaning where thoughts are conceived. This negative affective framework might
138 infuse with a certain negative character all the factors implicated in the formation and experience of thoughts109.
For instance, a certain external factor might be given a negative valence – i.e. egodystonic – and this would infuse the process of thought formation with a negative character; a certain situational factor such as being forced to make my own decisions can have an associated aversive character. In this context, it seems plausible to think that we can attach egodystonic feelings to any of the triggering and constraining factors described by Martin & Pacherie and that therefore, negative affectivity might play a crucial role in the early stages of the development of delusions of thought insertion. Certainly, this understanding of the relationship between affectivity and the process of thought formation might contribute to the picture that current deficits approach have of the target phenomenon.
Now, it is important to note that, unlike the TAH, our suggestion does not take aversiveness or egodystonicity as sufficient for a thought to be externalized. Negative character does not imply alienness. Negative affectivity is just one element related to the deficit aetiological picture of thought insertion. An adequate account of thought insertion needs to explain why egodystonic thoughts, such as immoral or obsessive thoughts are not externalized, i.e. why they are not delusional in nature. Along with other factors, egodystonicity and aversiveness may indeed be a necessary condition for a person to externalize certain thoughts under pathological circumstances, but it is by no means a sufficient condition. Certainly, thought insertion cannot be explained solely on the basis of affective impairments. Such a suggestion would lead to an incomplete picture of the same kind offered by current deficit views (and that we are trying to complete). A psychotic phenomenon like thought insertion might arise as the result of a complex interaction between different faulty mechanisms at different levels. Thus, a second factor impairment might be required to explain why patients go from aversion – or egodystonicity – to externalization. Endorsing a suggestion made by advocates of ‘two-factor theories’ of delusions, we can explain the route from aversion to externalization in terms of patients’ inability to reject implausible beliefs once they are suggested by first-factor experiential phenomena (see Davies, Coltheart, Langdon & Breen, 2001; Coltheart, Langdon & McKay, 2007). For example, the adoption of delusive beliefs might be based on the interaction of
109 It is possible to link this idea with the main claims of paper 1 and 2 of this compilation. Arguably, the structuration of a generally negative affective context might influence various aspects of the phenomenology of conscious thoughts, among them, their affordances. It seems plausible to say in light of the evidence and the affordance framework sketched in paper 1 and 2 the that affective impairments would be one of the key elements that might be implicated in the change of affordances in certain abnormal phenomenally available thoughts.
139 affective and perceptual impairments. Apparently, the second factor cognitive impairment might not be present in patients suffering from OCD and, in turn, this would account for the non- delusional nature of egodystonic obsessive and immoral thoughts. Another option is to say that in cases of OCD and immoral thoughts, there is no underlying affective impairment and therefore, although egodystonic in content, subjects remain able to deal with such thoughts in a non- delusive way.
However, there is another element that might help us to distinguish between immoral and obsessive thoughts and inserted thoughts. Unlike in cases of obsessive thoughts, inserted thoughts are given in a general delusional context (Fuchs, 2005). For example, Roberta, a patient diagnosed with schizophrenia, claims that her episodes of thought insertion were always preceded by general transformations of her experience of the world, a phenomenon ‘lasting even weeks’ (unpublished interview). Arguably, this delusional context, known as ‘delusional mood’, when added to underlying affective, perceptual, and cognitive impairment is another important factor that leads patients to externalize certain thoughts. This context is not present in cases of OCD. However, it is important to note in this context that further research about the causal relationship between delusional moods and specific delusional episodes is needed110.
Up to this point, I have claimed that affective impairments should be understood not only as the result of the anxiety and stress produced by delusional episodes, but also as an important doxastic force in the process of forming delusions of thought insertion. This suggestion is not only consistent with the empirical evidence discussed in section 3, but also with the current trend in psychiatry concerning the general understanding of the relationship between affective and psychotic disorders. Traditionally, diagnostic systems of mental illness have maintained a sharp distinction between these two types of disorders. However, this distinction is currently under examination based on the idea that affective factors are a key element in the development of psychotic disorders (Birchwood, 2003; Fuchs, 2013). For example, it is suggested by Häfner, Maurer and Hide (2013) that psychotic and affective disorders are indistinguishable in their early stages, until the emergence of clear bizarre psychotic symptoms that, in turn, might be based on affective impairments. Marwaha et al. (2013) have recently claimed that this traditional distinction overlooks the crucial role that impairments in affectivity may have in the process of forming delusions. This tradition has certainly influenced the way in which current approaches to
110 Most approaches to delusions have overlooked the examination of the role that the context of the occurrence might have in the aetiology of delusional episodes. I explore this issue in the third and fifth paper of this compilation.
140 thought insertion have conceptualized the phenomenon and it is the tradition we have been trying to challenge in this paper.
7. Exploring a Theoretical Integration
Thought insertion is a complex phenomenon and, in trying to understand it, deficit approaches neglect the role that affectivity impairments play in its aetiology. As a consequence of this, deficit accounts have missed a number of advantages usually associated with motivational accounts. Now, some people might suggest that the attempt to explaining all cases of thought insertion using one single model is too ambitious. However, in this section, a more fruitful path is taken as I explore the way in which our analysis can complement and complete the current two- factor view of thought insertion.
Although the TFV enjoys a well-deserved popularity, it seems to face some difficulties in cases of thought insertion that might be overcome by recognising that egodystonic states play a crucial role in the aetiology of this delusion. The TFV identifies first-order neuropsychological impairments as leading to anomalous thoughts. However, it is noted that there are several cases of delusional patients where no neuropsychological impairments can be identified (Butler, 2000; McKay, Langdon & Coltheart, 2009). In fact, the case has not been clearly made for cases of thought insertion. It is observed that most of the evidence regarding neuropsychological impairments related to thought insertion is established by analogy with the evidence for existing impairments in cases of alien control of movements (Walsh, Oakley, Halligan, Mehta & Deeley, 2014). Synofzik et al. (2008) have criticized this analogy; they argue that, unlike movements, thoughts do not have sensorimotor characteristics to inform a feed-forward inhibition of the self- monitoring system, which is the subpersonal mechanism claimed to be defective in cases of delusions of alien control (Frith, 1992)111. Consequently, it is not clear that the impairments identified in cases of alien control can actually lead to the formation of delusions of thought insertion. The problematic nature of this analogy suggests that, without the clear identification of a first-factor impairment, the TFV seems unable to provide an explanation consistent with its main explanation of delusions.
This difficulty can be resolved by endorsing the view that affective impairments can, under certain circumstances, act as a source of first-order experiential input, as in cases of thought insertion for example. This suggestion is not only empirically well-supported but also
111 A more complete critique of this parallelism can be found in paper 1 of this compilation.
141 consistent with the conceptual framework of the TFV. On the TFV, the first-factor deficit involved in thought insertion seems to be understood as an unconscious evaluation disorder (Fine, Craigie & Gold, 2005). Consequently, when no neuropsychological impairment can be identified, it is plausible that affective impairments involved in the process of thought formation lead to abnormal thoughts (first-factor) which along with impairments in the belief evaluation system (second-factor), might lead to the conscious experience of thought insertion.
Another difficulty for the TFV is suggested by Fine, Craigie and Gold (2005). They argue that if we are to explain the route from abnormal experience to delusions as being the result of a defective belief evaluation system, ‘[we] would predict that patients would come to accept the many odd thoughts that occur to them as well as to normal individuals’ (p. 162). However, schizophrenics do not experience all their odd thoughts as alien. In defence of the TFV, one might reply that the belief evaluation system in thought insertion is defective but not completely inoperative (cf. Fine, Craigie & Gold, 2005, p. 162). Prima facie, this reply seems unsatisfactory, for it cannot explain the selectivity and specificity of inserted thoughts.
However, this difficulty might be overcome by endorsing the idea that egodystonic states act not only as a first-factor source of input, but also as a second-factor. The second-factor in the TFV is supposed to explain why delusional beliefs are adopted and maintained. Arguably, a certain explanatory hypothesis is endorsed as more plausible than its alternatives, for the benefit it confers, namely, as a way of dealing with first-order abnormal thoughts. Thus, the avoidance of certain egodystonic states provides a set of constraints for the functioning of this not completely inoperative system of belief evaluation. As McKay, Langdon and Coltheart (2009) suggest ‘it may be that incoming doxastic information is processed so as to yield beliefs that allow the individual to function adequately in the world by virtue of (a) closely approximating reality; and (b) allowing the individual a measure of security and satisfaction’ (p. 175). By the same token, our complementary suggestion might also explain why delusional beliefs are maintained despite evidence to the contrary. As Frankish (2011, p. 27) points out ‘perhaps patients adopt delusions because they answer some emotional or other psychological need, rather than because they are probable’.
8. Concluding Remarks
In making sense of delusions of thought insertion, current deficit approaches have neglected the role that disrupted affectivity might have in the aetiology of delusional phenomena such as thought insertion. In this paper, I have examined a broader view of the process of thought
142 formation that allows us to make sense of the existing evidence on impaired affectivity in the psychogenesis of thought insertion. Thus, the offered analysis might contribute to a more complete two-factor view of the phenomenon. One of the advantages of this alternative way of understanding the relationship between thought formation and affectivity is that it overcomes the limitations of the thought-aversion hypothesis and Graham and Stephens’ (1994) critique of this hypothesis. In the context of the occurrence of thought insertion the TAH struggle to explain cases with no explicit egodystonic content, while the problem for Graham & Stephens is to make sense of the negative nature that characterizes most cases of the delusion. If we understand the role that affective and affectivity-laden states have in the formation of delusions not purely in terms of their relationship with the manifested delusive content but also as triggering and constraining factors, we might be able to make sense of all cases of thought insertion from a deficit point of view. Thought insertion might not only involve perceptual and cognitive impairments, but also important affective preconditions. These preconditions relate not only to thought-contents but also to the formation of such contents.
Let me finish with some brief reflections on the practical importance of our analysis for the treatment of delusions. Consider cognitive behavioural therapy (CBT), one of the most popular current approaches to the treatment of delusions. CBT focuses on the idea that by reflecting on and then modifying their patterns of thinking, patients can learn how to cope with delusional beliefs (Maiese, 2014). One of the most important components of the CBT is the process of questioning the consistency and plausibility of delusions in order to evaluate and encourage alternative beliefs in patients (Chadwick, Birchwood & Trower, 1996). CBT constitutes, so to speak, a top-down mode of intervention; its psychotherapeutic analysis goes from belief to experiences. One of the main problems with this view however, is that the role of affectivity is seen as secondary or sometimes not even addressed (Skodlar et al, 2012). Like most deficit-based approaches to the treatment of delusions, CBT does not seem to consider affective states as important doxastic forces causally implicated in the aetiology of delusional episodes. Therefore, CBT seems to be importantly incomplete. I agree that the treatment of delusions must include top-down interventions, given that the delusive belief itself is the most immediately available information which patients can bring with them in the context of psychotherapy. But at the same time, psychotherapeutic interventions should also include bottom-up elements, namely, analyses from experience to beliefs. As argued in this paper, delusions might be based on a number of deficits, such as affective impairments. Most delusional beliefs are produced in a context of disturbed affectivity and they only make sense to the patient within such a context (Marwaha et al. 2013). Perhaps the clarification, description, and evaluation of the affective
143 context in which certain delusions are produced might help to predict the occurrence of future delusional episodes. Thus, the promotion of a better understanding of the patient’s affective circumstances preceding her delusional episodes might help to (i) explore ways of preventing the emergence of such phenomena by the monitoring of strong affective changes and, (ii) explore different ways of coping with delusions in certain circumstances. Eventually, all of this might help therapists to elaborate more focused strategies of intervention in the treatment of delusions.
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147 Psychosis and the Subjectivity of Phenomenal Consciousness
Summary
Often, philosophers defend the existence of a strong link between phenomenal consciousness and self-awareness. The idea is that whenever one is aware of an experience, one can become aware of oneself as the subject of that experience. However, although we might intuitively agree on the existence of such a link, we can still disagree about its basic nature. This is the problem about the subjectivity of phenomenal consciousness. Philosophers endorsing a self-presentational view maintain that an experiential sense of mineness intrinsic to all conscious experiences is a necessary condition for a subject to become self-aware. The type of self-awareness entailed by phenomenal consciousness necessarily requires an experiential sense of mineness to exist. This paper claims that cases of thought insertion undermine this latter stronger idea and that such an experiential requirement plays little role in accounting for the most minimal type of subjectivity entailed by phenomenally conscious experiences. After clarifying the context and key aspects of the debate, the standard replies offered by the advocates of the self-presentational view are evaluated. It is concluded that although these replies add a number of interesting elements to the discussion, they do not do their job properly. In the final section, the main conclusion is strengthened by appealing to the phenomenology of cases of depersonalization and Cotard delusion.
A shorter version of this paper has been published as a chapter titled ‘Self-Awareness and the self-presenting character of abnormal conscious experiences’ contained in the book ‘Altered Self and Altered Self-Experience’.
Acknowledgment: I would like to thank Prof Mark Textor, Dr Tom McClelland, Dr Alexander Gerner, Dr Mauricio Otaiza, Dr Leo Tarasov, Patrick Friel, and Prof Dr Thomas Fuchs for helpful comments on earlier drafts of this article. Different sections of this paper were presented at the University of Oxford, New University of Liston, Vrije Universiteit Amsterdam, and the Universität Salzburg.
148
Nothing alien happens to us, but only what has long been our own... Rainer Maria Rilke
1. Introduction
Philosophers from different traditions have defended the existence of astrong link between phenomenal consciousness and self-awareness (Brentano, 1874; Jaspers, 1963; Flanagan 1992; Carruthers 1996; Rosenthal 1997; Zahavi 2005a, 2011; Kriegel, 2009)112. The idea is that whenever one is aware of a mental state, one can become aware of oneself as the subject of that state. Thus, awareness of experience would entail some form of awareness of ourselves. However, although we might intuitively agree on the existence of such a link, we can still disagree about its nature and the best way to characterize it. This is the problem about the subjectivity of phenomenal consciousness.
Philosophers defending a self-presentational view of consciousness claim that the existence of an experiential sense of mineness intrinsic to all phenomenally conscious experiences is a necessary condition for a subject to be self-aware113. This paper maintains that cases of thought insertion undermine this idea and that such an experiential requirement plays little role in accounting for the most minimal form of subjectivity entailed by phenomenally conscious experiences. After clarifying the context and key aspects of the debate (Section 2 & 3), the standard replies offered by the advocates of the self-presentational view are critically evaluated (Section 4). It is concluded that although these replies add a number of interesting elements to the discussion, they do not do their job properly. In the final section, the main conclusions of the analysis are strengthened by appealing to the phenomenology of depersonalization and Capgras delusion.
2. Mineness and Self-Consciousness: Mapping the Debate
Contrast the experience of believing that P and desiring that X. Although these two conscious experiences differ in their intentional content (P and X) and propositional attitude (believing and desiring), some philosophers claim that they share a common feature. In both
112 Block (1995) formulates the concept of phenomenal consciousness as follows: ‘P-consciousness [phenomenal consciousness] is experience. P-conscious properties are experiential properties. P-conscious states are experiential, that is, a state is P-conscious if it has experiential properties’ (1995, p. 230). 113 In this paper I use the terms ‘self-consciousness’ and ‘self-awareness’ interchangeably.
149 cases, they are your own experiences. Recently, discussions on the nature of the so-called mineness of conscious experience have become increasingly important in the context of the debate about the ways in which some psychotic symptoms challenge our strongest intuitions about the subjective character of human consciousness (Parnas & Sass, 2003; Metzinger, 2003; Bayne, 2004; Zahavi, 2005a; Grünbaum & Zahavi, 2013; Lopez-Silva, 2014a; 2014b; Billon, 2013; Billon & Kriegel, 2015). However, despite its theoretical and practical relevance, the very notion of mineness is rather unclear.
A common way of thinking about mineness is to suggest that it represents a phenomenal aspect of conscious experiences i.e. it figures in the phenomenology of normal conscious experiences114. In this sense, the notion of mineness is related to the way our experiences commonly feel. Here, mineness refers to a phenomenal ‘sense’ that accompanies the appearance of experiences in one’s stream of consciousness115. The idea is that the mental states I am aware of are not only necessarily mine, but also, they feel as my own mental states; they are commonly given to me as my own states. People endorsing this view of mineness usually disagree about whether the presence of this property in the phenomenology of conscious experiences is necessary or contingent. On the one hand, the moderate camp claims that only some conscious states involve mineness as an experiential component and therefore, this property might not be intrinsic to the phenomenal structure of conscious experiences as such (see Metzinger, 2003; 2006; Blanke & Metzinger, 2009; Lane, 2012; 2015; López-Silva, 2014a). On the other hand, the liberal camp maintains that all conscious states involve experiential mineness as an intrinsic constituent (Gallagher & Zahavi, 2008; Zahavi, 2005a; 2011; Grünbaum & Zahavi, 2013; Gallagher, 2012; 2015).
The second relevant dispute here concerns the role that the sense of mineness plays in the understanding of the subjectivity of consciousness. The so-called subjectivity theories of consciousness appeal to the sense of mineness to explain the existence of a necessary experiential link between phenomenal consciousness and self-consciousness (Billon & Kriegel, 2015). A number of renowned philosophers are claimed to have endorsed this form of theory of consciousness over time. For example, Jaspers (1913) suggests that:
114 A rather different way of thinking about this issue is to claim that the notion of mineness is just a philosophical resource with no experiential reality whatsoever and therefore, it targets a conceptual truth about the relationship between a subject and her mental states. I will not analyse further no-experiential views here because our discussion concerns an approach that takes mineness to be an experiential aspect of phenomenal consciousness. 115 This property has been named in a number of different ways: ‘sense of mineness’ (Parnas, Møller, Kircher, Thalbitzer, Jansson, Handest & Zahavi, 2005a; Zahavi, 2005b), ‘for-me-ness’ (Zahavi, 1999); ‘my-ness’ (Frith, 1992), or ‘meishness’ (Billon, 2013). Zahavi (2005a; 2011) and Grünbaum & Zahavi (2013) use the terms ‘mineness’ and ‘ownership’ interchangeably.
150
Self-awareness is present in every psychic event... Every psychic manifestation, whether perception, bodily sensation, memory, idea, thought or feeling carries this particular aspect of ‘being mine,’ of having an ‘I’-quality, of ‘personally belonging,’ of it being one’s own doing. We have termed this ‘personalization.’ (Jaspers 1913, p. 121)
All subjectivity theories of consciousness are committed to the self-consciousness claim:
Self-Consciousness Claim (SCC): whenever one has an experience of any kind, one is not only aware of the experience but also aware of oneself as the subject of that experience. Therefore, phenomenal consciousness necessarily entails self-consciousness.
There are three main types of subjectivity theories of consciousness. According to higher- order theories of consciousness – ‘HOT’ henceforth – subjective phenomenal states are those that a subject is not only aware of, but she is also aware of as her own states (Rosenthal, 1990). As Flanagan (1992, p. 194) puts it: ‘all subjective experience is self-conscious in the weak sense that there is something it is like for the subject to have that experience [phenomenal character]. This involves a sense that the experience is the subject’s experience, that it happens to her, occurs in her stream [subjective character]’. Self-awareness within HOTs is the result of higher-order representation of the subject’s experience, so it is understood as the result of a top-down representational mechanism116. Subjects come to claim that certain mental states are their own mental states because they represent these states as their own.
A second class of subjectivity theory are self-representationalist theories of consciousness (Kriegel, 2003; 2009). Here, the sense of mineness is not understood as the product of a mental state being targeted by a higher-order representation but rather as the mental state being targeted by itself117. On this view, a mental state does not only represent itself but also represents itself as belonging to the subject, and, it is in virtue of this intrinsic self- representational nature that subjects become aware of these states always as their own (sense of mineness). This theory clearly represents another instance of the SCC, as Billon & Kriegel (2015) claim: ‘the fact that the conscious state is represented by itself means that it is represented by a
116 For a critique of HOT, see Zahavi & Parnas (1998). 117 This idea can be already found in Brentano (1874) who claims that: ‘[Every conscious act] includes within it a consciousness of itself. Therefore, every [conscious] act, no matter how simple, has a double object, a primary and a secondary object. The simplest act, for example the act of hearing, has as its primary object the sound, and for its secondary object, itself, the mental phenomenon in which the sound is heard’. (pp. 153-155).
151 conscious state, which in turn means that the subject’s awareness of it (as hers) does show up in the subject’s overall phenomenology’ (p. 3).
Finally, according to the self-presentational view of consciousness – SPV henceforth – a phenomenal first-order sense of mineness contained in the intrinsic intentional structure of all conscious experiences is responsible for the necessary experiential link between phenomenal consciousness and self-consciousness (Zahavi, 1999; 2005a; 2007; 2011; Gallagher & Zahavi, 2008; Grünbaum & Zahavi, 2013)118. The SPV identifies this first-order sense of mineness contained in all experiences with a minimal form of self-awareness119. In other words, self- consciousness is instantiated in all episodes of phenomenal consciousness by a phenomenal sense of mineness. The remainder of this paper focuses on this class of subjectivity theory of consciousness.
2. The Self-Presentational View of Consciousness
2.1. From Consciousness of Experiences to Self-Consciousness
Only a few philosophers within the current phenomenological tradition have been as devoted as Dan Zahavi to the understanding of the subjectivity of consciousness. Mostly grounded in the thought of Brentano and Husserl, Zahavi’s SPV suggests that consciousness always involves experiential awareness of oneself as the subject of experiences. At the same time, he suggests that this self-awareness is intrinsic to the structure of all conscious experiences (Zahavi, 2005a, 2011; Gallagher & Zahavi, 2008)120. Thus, self-consciousness is not a property that one adds or infers from phenomenally available experiences as, for example, HOTs might claim121.
When undergoing a conscious state – drinking a glass of Chilean Cabernet Sauvignon for example – your attention is focused neither on yourself nor on your experience of drinking. So to speak, you are immersed in this conscious episode. However, when asked what you are doing, you quickly reply that you are drinking wine with no need of further reflection on your ongoing
118 By ‘self-presenting approach’ I refer to the view defended mainly by Dan Zahavi and summarized in ‘Subjectivity and Selfhood’ (Zahavi, 2005a). I use this expression in order to distinguish between Zahavi’s account and other views also grounded in the phenomenological tradition. I thank to Prof Mark Textor for this recommendation. 119 In fact, Zahavi (2005a) attributes this claim to all the major figures of the phenomenological tradition such as Husserl, Sartre, and Heidegger. For a critical review of this idea, see Schear (2009). 120 First, Zahavi employs the terms self-awareness and self-consciousness indistinctively. Second, Zahavi is not committed to an inference from self-awareness to awareness of the self qua self i.e. from a phenomenal to a metaphysical self. When referring to self-awareness and minimal self, I will be referring to the discussion about a phenomenal self. 121 The term ‘intrinsic’ is explicitly meant to distinguish Zahavi´s view from higher-order theories of self- consciousness (Zahavi, 2011, p. 57, note 1).
152 state. You do not have to stop and think about what you were doing; you do not discover that you are drinking wine, nor do you discover that it is you who is doing the drinking. Rather, you just know what you were doing (in a quite liberal sense of the expression ‘to know something’).
In explaining this, Zahavi (2005a) appeals to the existence of two modalities of self- awareness. The most basic form is not something acquired at the moment of being asked what you were doing, but rather an awareness of yourself that has been pre-reflectively present all along. As Zahavi (2005a) claims: ‘it is because I am pre-reflectively conscious of my experiences that I am usually able to respond immediately, that is, without inference or observation, if somebody asks me what I have been doing, or thinking […] prior to the question’ (p. 21, my emphasis). The notion of pre-reflective self-awareness refers to a non-conceptual and non- observational experiential awareness of oneself that figures as a subtle presence in all our conscious activities (Zahavi 2005a, pp. 158, 267, 291). Within the SPV, any form of more robust reflective self-awareness – such as a narrative self-awareness – is rooted in this subtle acquaintance we have with our conscious experiences that is claimed to be prior to any attentional move towards them. Importantly, Zahavi suggests that the notion of pre-reflective self-awareness is not only phenomenologically compelling, but it also constitutes the best conceptual alternative to explain the way we become aware of ourselves in having phenomenal experiences122.
2.2. From a Sense of Mineness to Self-Consciousness
The SPV not only claims that (i) phenomenal consciousness necessarily involves experiential self-awareness (SCC) but also, (ii) that this self-awareness necessarily requires a sense of mineness to exist. On the SPV, a phenomenal first-order sense of mineness is responsible for the experiential pre-reflective self-awareness that we – allegedly – enjoy in our everyday conscious life (see section 2.1.). Zahavi (2005a) claims that a careful examination of our conscious experiences reveals the fact that they are always given to me as my experiences; they are fundamentally characterized by an intrinsic phenomenal sense of mineness (pp. 124-132). In this sense, the SPV takes a liberal stance towards the presence of a sense of mineness in conscious experience. As Zahavi and Kriegel (2015) claim: ‘the for-me-ness of experience is a universal feature of experience’ (p. 1). Thus, contrasting with what HOT claims, Zahavi (2005a) maintains that: ‘whether a certain experience is experienced as mine or not, however, depends not on something apart from the experience [an additional mental state], but precisely on the givenness of the experience’ (p. 124).
122 People like Schear (2009) disagree with this.
153
By claiming this, Zahavi (2005a) identifies the experiential sense of mineness with a minimal form of self-awareness that would be intrinsically contained in the structure of all conscious experiences: ‘it is also possible to identify this pre-reflective sense of mineness with a minimal, or, core, [phenomenal] sense of self’ (p. 125). The idea here is that in becoming aware of a certain experience pre-reflectively as mine, one becomes necessarily aware of being the subject undergoing that experience so the self-attribution that the sense of mineness allow secures the subjective character of all conscious experiences. As we can see, on this view, the sense of mineness is part and parcel of the explanation of the subjectivity of consciousness as it provides the experiential datum for the advocate of the SPV to claim a necessarily experiential link between phenomenal and self-consciousness.
Now, let me clarify some of the main aspects underlying Zahavi SPV’s general argumentation:
2.2.1. Phenomenal Character
Conscious experiences are claimed to have phenomenal character, this means that there is something that is like for the subject of the experience in question to be in. The notion of what it is like is an ambiguous one.
Philosophers defending an intentionalistic approach claim that experiences acquire their phenomenal character from the objects they represent. In experiencing a certain object, there is nothing over or above the intentional object of the experience; if there is something that is like to taste a glass of wine it is because of the specific qualitative features of the wine (dryness, bitterness, fruitiness, etc.). On this view, one can distinguish the experience of tasting wine from others given through the same experiential modality (tasting) for they refer to objects with different qualitative properties (water, tea, beer, etc.). When one has a conscious experience, all that one is conscious of are the objects and the features of the objects that experiences are experiences of (see Tye, 1995).
This idea is closely related to G.E. Moore’s notion of the diaphanous quality of conscious experience. Specifically, when one tries to focus one’s attention on the intrinsic features of experience, one always ends up attending to what the experience is of. In other words, the phenomenal character of experience is a quality of that which is being represented by the experience (Dretske, 1991). It is not my intention to offer an exhaustive critique of this position here; however, it seems hard to explain from an intentionalistic standpoint how we can
154 phenomenologically distinguish between different types of experiences referring to the same intentional object. One thing is to explain our ability to distinguish between experiences given through the same experiential modality and representing qualitatively different objects (tasting wine, tasting tea, tasting milk, and so on), but quite another is to explain our ability to distinguish between different types of experiences referring to the same intentional object. If the intentional object is all one has access while having an experience, experiences about the same content but given through different experiential modalities would be indistinguishable in a single subject’s field of awareness. This clearly contrasts with fact that we do have the ability to experientially distinguish between tasting a glass of wine, thinking of a glass of wine, desiring having a glass wine, and so on.
Contrasting with intentionalistic views, Zahavi’s argumentation relies on the notion that conscious experiences have a distinctive phenomenal character that is different from the qualities of the intentional objects they represent. This is not to say that the qualitative properties of the objects represented by experience are irrelevant but rather, Zahavi claims that when aware of a certain object, one is also aware of being in that state, the awareness of this experiencing entailing a distinctive character over and above the intentional content of the experience. There is something that is like to be in a certain experiential state that is different from the qualitative properties of a certain experienced object.
In this context, Zahavi (2005a, p. 121) argues that the question about phenomenal character has two sides: ‘there is a difference between asking about the property the object is experienced as having (what does the object seem like to the perceiver) and asking about the property of the experience of the object (what does the perceiving feel like to the perceiver)’. Both the properties of the objects and the properties of the experiential modalities through the objects are given are claimed by Zahavi to be part of the phenomenal character of conscious experiences. Finally, Zahavi explains that: ‘the reason we can distinguish [distinct] occurring conscious mental states from each other is exactly because there is something it is like to be in those states’ (Zahavi, 2005a, p. 119). Thus, on this view, we distinguish between experiences with the same intentional content because these different experiential modalities each have a distinctive feel.
2.2.2. Double Structure of Conscious Experiences
The aforementioned conception of conscious experience allows Zahavi to distinguish between the qualitative character of a certain intentional object (sensed) and the qualitative
155 character of the experiential modality through which the object is given (sensing) as two inseparable moments of conscious experience123:
When I touch the cold surface of a refrigerator, is the sensation of coldness that I then feel a property of the experienced object or a property of the experience of the object? The correct answer is that the sensory experience contains two dimensions, namely one of the sensing and one of the sensed, and that we can focus on either (Zahavi, 2005a, p. 123)
Zahavi suggests that although these two dimensions are conceptually distinguishable one from the other, they are always part of the same phenomenon. In other words, they cannot be phenomenologically separable. This alleged double phenomenal structure leads Zahavi (2005a) to suggest that we should change our way of referring to experiences: ‘instead of saying that we experience representations, it would be better to say that our experiences are presentational, that they present the world as having certain features’ (p. 120).
2.2.3. Subjective Character
One of the most relevant phenomenological claims made by Zahavi is that the qualitative character of an experience (what it’s likeness) necessarily entails subjective character. In virtue of this relation, Zahavi links phenomenal availability to self-awareness. In fact, Zahavi seems to problematically equate these two properties:
Experiences have a subjective ‘feel’ to them, that is, a certain phenomenal quality of ‘what it is like’ or what it feels like to have them (Zahavi 2005a, p. 116, my emphasis).
Every conscious state, be it a perception, an emotion, a recollection, or an abstract belief, has a certain subjective character, a certain phenomenal quality of ‘what it is like’ to live through or undergo that state (Zahavi 2005a, p. 119, my emphasis)
Zahavi argues that the quality of what it is like is always what it is like to be in a certain state for a subject and therefore, phenomenal and self-consciousness cannot be distinct phenomena (Zahavi & Kriegel, 2015). In other words, this link has an experiential reality (see Zahavi, 2005a, pp. 116-124). If there is something that is like to taste a nice Cabernet Sauvignon, there is necessarily something that it is like to be in that state for a subject. Zahavi (2011)
123 Zahavi (2005a) explicitly follow Husserl’s distinction between intentional matter and intentional quality of experience (p. 117).
156 concludes that: ‘the question of self-awareness is not primarily a question of a specific what, but of a unique how. It does not concern the specific content of an experience, but its unique mode of givenness’ (2005a, p. 204). As Zahavi (2011) puts it: ‘[self-awareness] is not something added to the experience, an additional mental state, but rather an intrinsic feature of the experience’ (p. 56- 57, my emphasis).
The problem is that the step from phenomenal to self-consciousness is neither obvious nor guaranteed (see Siewert 2013 for instance). One might actually say that phenomenal character qua phenomenal character does not necessarily entail self-awareness for they can be instantiated independently. It is possible to think of animals enjoying phenomenal consciousness without necessarily enjoying self-awareness, or at least, the type of self-awareness that Zahavi seems to attribute to phenomenally conscious experiences. Perhaps, one might also think of a possible world where zombie-like entities enjoy phenomenal experiences without enjoying self- awareness. Less controversially, philosophers such as Nietzsche (1968) suggest that: ‘the ‘subject’ is not something given, it is something added and invented and projected behind what there is’ (p. 267) and in the same line, Carnap (1967) claims that: ‘egocentricity [Ich- Bezongenheit] is not an original property of the basic elements of the given’ (104). The point I shall make here is that given that we can think of phenomenal and self-consciousness as distinct phenomena, claiming that the former necessarily entails the latter is a substantive thesis that needs to be scrutinized rather than a claim that is entailed by the meaning of the term ‘phenomenal consciousness’ as Zahavi seems to propose. This issue is the focus of the next section.
3. The SPV and the Challenge from Psychopathology
Over the last years, three kinds of general objections have been raised against subjectivity theories of consciousness, namely, introspective objections (Dainton, 2004; Bermudez, 2011), explanatory objections (Schear, 2009), and objections from psychopathology (Metzinger, 2003; López-Silva; 2014a; Lane, 2012; 2015)124. This section formulates this latter class focusing on the way in which the phenomenology of thought insertion undermines the main argumentation of the SPV125. The phenomenology of psychosis is fundamental in this context as ‘[it] consists not only in abnormal contents of experience (e.g. strange, peculiar or erroneous ideation, varieties of
124 From a brief treatment of these three types of objections, see: Zahavi & Kriegel (2015). 125 A careful examination of this view seems fairly justified in light of its the current influence in disciplines such as psychopathology and psychiatric diagnosis (Parnas, Møller, Kircher, et al. 2005), philosophy of mind and cognitive sciences (Gallagher & Zahavi, 2008), and developmental psychology research (Zahavi, 2005a), just to name a few.
157 hallucinations, etc.) but may reflect the altered forms of subjectivity’ (Cermolacce, Naudin & Parnas, 2008, p. 705). I shall note here that the examination on this section is not meant to undermine the plausibility of the claim that phenomenal consciousness entails some form of subjectivity. Rather, it is focused on the role that the sense of mineness should be given in explaining such a link.
Should we think about an experiential sense of mineness as part and parcel of the explanation for the most minimal form of subjectivity entailed by phenomenal consciousness? I’m not entirely convinced that we should. As Bayne (2004) rightly points out: ‘while it is a necessary truth that there is something it is like to have (phenomenally) conscious experiences, I don’t think that the ‘what it’s likeness’ of experience entails, or necessarily brings with it, a sense of ownership’ (p. 231). This is by no means to deny that there is a subjective dimension to phenomenal consciousness. Rather; that an experiential sense of mineness (or ownership) would play little role in explaining this subjective character. It looks perfectly plausible to think of the subjectivity of phenomenal consciousness and the sense of mineness as distinct phenomena so the challenge is to demonstrate whether they can actually come apart phenomenologically.
Here, the phenomenology of delusions of thought insertion becomes crucial. Patients suffering from this delusional experience report that certain thoughts or ideas are placed into their minds by external agents such as persons (e.g. TV celebrities, relatives), devices (e.g. TVs, radios), collective groups (e.g. aliens, the government, secret societies), or surrounding inanimate entities (e.g. houses, trees), among many others (see Schneider, 1957; Mellor, 1970; Frith, 1992; Mullins & Spence, 2003). These are some of the classic reports on this delusion:
Sometimes it seemed to be her own thought . . . but I don’t get the feeling that it is.’ She said her ‘own thought might say the same thing . . . But the feeling it isn’t the same . . . the feeling is that it is somebody else’s . . . (Allison-Bolger, 1999, # 89)
I look out of the window and I think the garden looks nice and the grass looks cool. But the thoughts of Eammon Andrews come to my mind. There are no other thoughts there, only his. He treats my mind like a screen and flashes his thoughts onto it like you flash a picture (Mellor, 1970, p. 17).
What patients seem to be implying in these cases is that certain thoughts that appear in their own stream of consciousness do not feel as their own thoughts and, arguably, the best
158 explanation for this seems to be that the thoughts in question lack an experiential sense of mineness. This suggestion seems to be supported by the following quote:
Patients report that ... the thoughts which occur in their heads [are] not actually their own. It is as if another’s thoughts have been ... inserted in them. One of our patients reported physically feeling the alien thoughts as they entered his head and claimed that he could pin- point the point of entry! (Cahill & Frith, 1996, p. 278, my emphasis)
In this context, people like Thomas Metzinger (2003) conclude that thought insertion demonstrates that the sense of mineness is ‘by no means a precondition of conscious experience’ (p. 334) for it shows self-aware subjects alienated from their own thoughts for which they experience neither a sense of mineness nor a sense of agency126. Cases of thought insertion make it phenomenologically evident that conscious experiences without an experiential sense of mineness can occur in self-aware subjects, and this is enough to suggest that such an experiential requirement is not really needed to explain the subjectivity of consciousness.
Explicitly referring to Zahavi’s view, Metzinger (2006, p. 3) proposes that delusions of thought insertion show that the sense of mineness is not ‘an invariant dimension of the first personal givenness’. In other words, these cases favour a moderate stance towards the presence of the sense of mineness in the occurrence of conscious experiences. At first glance, it seems plausible to conclude here that, contrary to what the SPV argues, thought insertion shows that it is possible to retain self-awareness (as thought insertion patients remain self-aware) without experiencing certain experiences as my own experiences and therefore, that the sense of mineness should not be taken as part and parcel of the explanation for the subjectivity of phenomenal consciousness127. However, things are not so straightforward and as a result of the challenge proposed by thought insertion, advocates of the SPV elaborate some replies. It is important to clarify here that although the just formulated challenge from psychopathology is not new, no specific evaluations of Zahavi’s replies can be found in current literature. The next sections are devoted to this task.
3.1. Thought Insertion as a Disruption in the Sense of Mental Agency
The first strategy of the defender of the SPV consists in the apparent endorsement of the so-called standard approach to thought insertion (Gallagher, 2004; 2014; Sousa & Swiney,
126 I will clarify the concept of sense of agency in the next section. 127 It is important to note that, following Husserl, Zahavi (2005a) claims that: ‘conscious thoughts have experiential qualities […] episodes of conscious thoughts are experiential episodes’ (p. 116). Thus, the SPV treats episodes of conscious thinking as experiential episodes and in consequence, the argument from thought insertion is valid.
159 2011)128. According to this approach, thought insertion patients are first-personally aware of thoughts that retain a sense of mineness and lack a sense of mental agency, i.e. the experience of being the voluntary author or producer of a thought129. Zahavi (2005a) maintains that: ‘when schizophrenics assert that their thoughts are not theirs, they do not mean that they themselves are not having the thoughts, but, rather someone else has inserted them and that they, themselves, are not responsible for generating it’ (p. 144, my emphasis). Explicitly replying to Metzinger’s objection, Zahavi (2005b) claims that: ‘rather than involving a lack of a sense of ownership, passivity phenomena like thought insertions involve a lack of a sense of authorship (or self- agency) and a misattribution of agency to someone or something else’ (Zahavi, 2005b, p. 6)130.
The strategy is rather straightforward. Zahavi offers a re-interpretation of the phenomenology of thought insertion that is meant to save his argumentation by appealing to a disrupted sense of agency and a retained sense of mineness in psychotic cases. Here, when schizophrenics claim that their thoughts are not their own, they do not express that they are not the subjects of that experience, but rather that a certain thought present in their stream of consciousness has not been produced by them (Zahavi, 2005b). I think this reply is problematic in a number ways:
First, the reply cannot discriminate between the particular phenomenology of inserted thoughts and the phenomenology of other cognitive experiences that can also be explained in terms of a disruption in the sense of agency and a retained sense of mineness131. Unbidden thoughts are thoughts that suddenly pop into our stream of consciousness. They ‘strike us unexpectedly out of the blue’ (Frankfurt, 1976, p. 240). However, although we cannot identify any experience of agency in their occurrence, they seem to preserve a sense of mineness; they feel as my own thoughts (see Gallagher, 2004). A second example is obsessive thoughts. They usually appear in our consciousness against our own will and with highly ego-dystonic contents. However, again, although we cannot identify any experiential sense of agency in their occurrence, they feel as our own thoughts.
128 This reply has been formulated in slightly different style in Zahavi (2005a; 2005b), and Grünbaum & Zahavi (2013). 129 This model has been widely criticized for providing an implausible picture of the phenomenon of thought insertion, see Bortolotti and Broome (2009); De Hann & De Bruin (2010); Fernández (2010); Martin and Pacherie (2013), among many others. 130 The distinction between agency and ownership was originally introduced at the level of attributions by Graham and Stephens (2000). Here, the ‘sense of agency’ is treated as a result of a (reflective) disposition to make judgments about one’s experiences. However, Gallagher (2004; 2012) introduces this distinction at the experiential level by suggesting that the ‘sense of agency’ belongs to the normal appearance of conscious experiences. It is important to distinguish between the experience of mineness and the attribution of mineness in this discussion since it will be the source of some of the problems that the self-presentational view faces. 131 This weakness iscommonly attributed to the standard approach; see paper 1 of this compilation.
160 As, Cermolacce, Naudin and Parnas (2008) conclude:
The obsessive thought or fantasy arises repeatedly against the patient’s will, often with a horrid content, and it immediately provokes or stimulates the reflective conscious attempts of suppression. Yet, the patient’s sense of ownership, sensing his horrid thoughts as being the products of his own mind, is completely intact with no complaints remotely similar to the alienation and anonymity observed in schizophrenia (p. 709).
Problematically, the phenomenology of unbidden and obsessive thoughts is quite different from the phenomenology of inserted thoughts and, as we can observe, Zahavi’s reply fails to capture this phenomenological difference. The distinction between sense of agency and sense of mineness does not satisfactorily account for the unique experiential character of thought insertion and leads Zahavi to provide an implausible re-interpretation of the phenomenon. In line with my counter-reply, Cermolacce, Naudin and Parnas (2008) conclude that: ‘it is therefore phenomenologically not accurate (and simply misleading for any further theoretical analyses) to ascribe to these phenomena [thought insertion] a failing sense of agency and to insist on a preserved sense of ownership (p. 709).
A related problem here is that Zahavi’s characterization of thought insertion cannot really explain the external attributions that patients make that are one of the marks par excellence of the symptom (Wing, Cooper & Sartorious, 1983). The reply cannot make sense of the fact that unbidden and obsessive thoughts, cognitive experiences lacking an experience of agency, are not attributed to external agents by the patients. When observing these gaps in Zahavi’s first reply, it seems plausible to maintain that what justifies the patients reports is not a mere lack of sense of agency, but rather, a more fundamental disruption in the sense of mineness. Perhaps, the very lack of this fundamental experiential feature is what makes patients to attribute the abnormal thought to an external agent (see for example, Synofnik, Vosgerau & Newen, 2008; Parrot, 2012; Martin & Pacherie, 2013, see paper 1 and 2 of this compilation). This option is certainly more plausible as it overcomes the just mentioned problem and it is capable of distinguishing between unbidden, obsessive, and inserted thoughts.
The second and most important problem with Zahavi’s reply is that it assumes an implausible picture of the normal phenomenology of thoughts to work. Zahavi (2005a, p. 143) takes thoughts to be normally experienced as something that one is doing, i.e. as involving a first-
161 order sense of agency in normal situations just like in cases of motor actions (see also Gallagher, 2014, p.2). Thus, this first-order experiential sense of agency would be missing in cases of thought insertion while the sense of mineness would be preserved. However, the truth is that not even normal thoughts are accompanied by an experience of mental agency so the reply does not really work132. This misleading picture comes from the author’s lack of specific treatment of the issue about mental agency as distinct from the discussion about bodily agency (see paper 1 of this compilation)133. As de Hann and de Bruin (2010) rightly observe: ‘the default mode in thinking is precisely not an explicit and wilful generation of thoughts’ (p. 383). It is observed that although the clauses that some people sometimes use to refer to their own thoughts might make them look like something deliberate, the actual experience of having thoughts is passive (Strawson, 2003). So to speak, thoughts appear in our stream of consciousness like dandelions so the phenomenology of thoughts should be characterized as fundamentally passive. If this is right and even the normal phenomenology of thought does not include an experiential sense of agency, Zahavi’s reply is untenable.
A second related issue here is that, in re-interpreting the phenomenon, it is noted that Zahavi comes to – conveniently – ignore what patients actually report134. Thought insertion patients do not refer to alien thoughts as not being something created by them, they clearly refer to them as something that does not feel as their own. As one of Jaspers’ patients (1963) report:
I have never read nor heard them; they come unasked; I do not dare to think I am the source but I am happy to know of them without thinking them. They come at any moment like a gift and I do not dare to impart them as if they were my own (my emphasis, p. 123).
When putting aside prior conceptual commitments (such as Zahavi’s view on the necessary role of the sense of mineness in the explanation of the subjectivity of consciousness), we should insist that cases of thought insertion show that it is experiential possible to preserve the subjective character of certain conscious experiences without these experiences enjoying an experiential sense of mineness. Therefore, contrary to what the SPV argues, an experiential sense of mineness would play little role in explaining the most fundamental form of subjectivity of consciousness (subjectivity that would be preserved in cases of thought insertion).
132 For a further argumentation of this idea, see paper 1 of this compilation. 133 Usually, the author equates the phenomenology of thoughts with the phenomenology of motor actions. Zahavi (2005a, p 143) claims that: ‘the sense of agency refers to the sense of being the author or source of an action or thought (Zahavi, 2005, p. 143, my emphasis). 134 It is important to note that Zahavi himself takes delusional reports as sincere reports on conscious experience with bizarre features (Zahavi, 2005a, Chapter V).
162 3.2. Stream of Consciousness and Sense of Mineness via Location
The second strategy used by Zahavi to deal with cases of thought insertion consists in claiming that the patients’ ability to locate the alien thought in their own stream of consciousness entails the retention of an experiential sense of mineness that is claimed for the whole stream. As Grünbaum and Zahavi (2013) claim, the retention of a sense of mineness here: ‘has to do with a thought simply appearing in “my stream of consciousness”’ (p. 225)135. Zahavi (2005a) claims that: ‘one should, however, not overlook that the subjects of thought insertions clearly recognize that they are the subjects in whom the alien episodes occur. They are not confused about where the alien thoughts occur; they occur in the patient’s own mind’ (p. 144, my emphasis). In a slightly different style, Grünbaum and Zahavi (2013) conclude that:
When a subject who experiences thought insertions or delusions of control reports that certain thoughts are not his thoughts, that someone else is generating these thoughts, he is also indicating that these thoughts are present, not ‘over there’ in someone else’s head, but within his own stream consciousness, a stream of consciousness for which he claims ownership (p. 235, my emphasis)
There are a number of confusions and problems underlying Zahavi’s second reply. First, this reply conflates the notions of a sense of subjectivity with the notion of a sense of mineness. In fact, the whole SPV’s argumentation shows this confusion. While a sense of mineness refers to the experience of a certain mental state as my own mental state, the sense of subjectivity refers to having phenomenal access to certain mental states as states that one is simply undergoing, i.e. states that are happening in my subjective space. The idea here is that there is something that is like for me to experience phenomenally available mental states and it is in this sense in which I cannot be wrong about whose mental states these are; they are my mental states because I am the one aware of their occurrence; I am the one undergoing them. This seems to be the most primitive modality of subjectivity entailed by the phenomenally conscious character of experiences that is preserved even in cases of thought insertion. However, this is quite different from what Zahavi takes to be the most minimal subjective character of consciousness.
135 The authors attribute this idea to Campbell’s (1999) proposal. However, the idea of mineness defended by Campbell does not seem to be consistent with the one defended by the self-presentational approach. In fact, Campbell (1999) claims something quite different: ‘What makes my occurrent thoughts mine is not just that they show up in my stream of consciousness. What makes them mine is, in addition, the fact that they are product of my long-standing beliefs and desires, and that the occurrent thinking can affect the underlying state’. (621).
163 In his general argumentation, Zahavi claims that every phenomenally available mental state (subjectivity) is experientially given to me as my own mental state (sense of mineness, see, Zahavi, 2005a; 2011; Zahavi & Kriegel, 2015, among many others). However, this is just not true. Experiencing a mental state as something that one is simply undergoing is quite different from experiencing a certain mental states as my own mental state and Zahavi conflates these two notions. The former does not necessarily entail the latter and Zahavi seems to neglect this subtle, but quite important, phenomenological distinction. Here, cases of thought insertion would show that a subject can be subjectively aware of a thought without feeling this thought as her own thought, i.e. without feeling a sense of mineness towards it, yet, retaining a sense of subjectivity. What thought insertion shows is that subjective phenomenal availability (subjectivity) does not necessarily entail mineness in the way Zahavi suggests so in this context, to insist that every experience is not only given to me, but rather, necessarily given to my as my own experience becomes question begging.
Thought insertion patients are phenomenally aware of an alien thought that does not feel as theirs: ‘the subject experiences thoughts which are not his own intruding into his mind. The symptom is not that he has been caused to have unusual thoughts, but that the thoughts themselves are not his’ (Wing et al., 1983; also see Mullins & Spence, 2003). Indeed, one of the most puzzling aspects of this delusion is that some phenomenally available thoughts occurring within the subject’s stream of consciousness are not felt as being the subject’s own thoughts (Bortolotti & Broome, 2008). If anything, thought insertion shows that certain thoughts lack the alleged sense of mineness and therefore, that the sense of mineness as an experiential component of conscious experiences seems to play little role in the explanation of the subjectivity of consciousness, at least, in the one preserved in these psychotic cases.
A second worry concerns the notion of stream of consciousness that underlies Zahavi’s line of argumentation. The author seems to defend the retention of a sense of mineness in cases of thought insertion by claiming that the alien thoughts are still the patients’ own thoughts because they can claim them to be in their own stream of consciousness from an experiential point of view (Gallagher, 2000; 2015; de Hann & de Bruin, 2010; Zahavi, 2005; Grünbaum & Zahavi, 2013). The idea here seems to be that that thoughts are my own because they feel as given in my own stream of consciousness or ‘in my mind’. Thus, the claim seems to be that I feel that I own the location or space in which those phenomenally available thoughts are given to me (see main quote above).
164 This view implausibly formulates the sense of mineness in terms of location, as if the stream of consciousness were a bucket where certain mental states are contained136. Rather than thinking of the stream of consciousness as the location of a thought, it is more plausible to think of it as the way in which we represent the occurrence of phenomenally available thoughts, or, as the way in which phenomenally conscious episodes simply occur. This issue is often referred as the unity of consciousness and all what it entails is that, when I focus my attention to them, phenomenally available experiences seem to be given as in an unified stream (Bayne & Chalmers, 2003; Bayne, 2010); it implies neither that mental states are experientially given to me as in my own stream nor that one has direct experiential access to this stream as the location of one’s thoughts137.
Arguably, here the category ‘my own stream’ seems to require a further inferential step of the type: ‘These experience are given as in a stream; I only have one stream of consciousness, and that stream is my own’ (see Vosgerau & Voss, p. 535). Thus, the notion of stream of consciousness would be related to the role of attention in organizing phenomenally available experiences. However, this would imply that we do not have a full experience of the stream of consciousness as such as Zahavi’s reply seems to require as for a subject to be able to claim an experiential sense of mineness for it. Here it is crucial to note that one thing is to say that mental states I have phenomenal access to are given as in a stream when I focus my attention to them, and quite another is to say that those experiences are given to me as in an stream that feels as my own. One does not seem to have direct phenomenal access to one’s stream of consciousness as such; rather, our phenomenally available experiences would be represented as being given in a stream.
Another problem in Zahavi’s second reply is that it establishes the retention of a sense of mineness by applying an implausible shift. First, it is clear that the alien thought necessarily occurs in the patient’s stream of consciousness, otherwise she would not be aware of it. This is what I have called subjectivity (what is not clear is whether we can really say that this stream is given to me as my own as Zahavi’s quote seem to entail). However, we cannot equate both the inserted thought and the stream of consciousness where the thought is given as Zahavi’s reply
136 A preliminary minor comment is that the reply goes against our common concept of ownership. As Bortolotti and Broome (2009) suggest: ‘If we think about the notion of ownership in general, spatial considerations are usually not sufficient to claim ownership’ (p. 217). These authors present a case where a child throws his ball into your garden. Here the ball does not become yours because you can merely locate it within the boundaries of your property. You have to provide evidence that the ball is yours, for example, by showing a receipt from the toyshop. In Zahavi’s reply, this element would be missing. As Bortolotti and Broome (2009, p. 217) concludes: ‘it is not sufficient for an object to be within one’s personal boundaries, or within the boundaries of one’s property, to be owned by that person’. 137 It is important to note that no-direct-access does not imply no-access at all.
165 does. Here, the retention of the sense of mineness is established by changing the target phenomenon from ‘thought’ to ‘stream of consciousness’. However, this move is neither sufficiently justified nor obvious. The problem is that Zahavi – along with people such as Gallagher for example:
Established the intactness of SO [sense of ownership] by subtly changing the target explanandum from “thought” to “mind.” If we however insist on keeping the target explanandum the same– i.e., if we keep focusing on the inserted thought itself– it is easy to see that both SA [sense of agency] and SO [sense of mineness] for the thought are distorted. They are precisely not “his thoughts” (De Hann & De Bruin, 210, p. 386).
As we can see, this explanatory shift in Zahavi’s argumentation cannot save the SPV from the challenge proposed by thought insertion and therefore, we should retain the interpretation of the phenomenon as a case where a self-aware subject is subjectively aware of a thought without experiencing a sense of mineness towards it.
The final problem with Zahavi’s second reply is that it does not really show the presence of an experiential sense of mineness in the patients’ reports. Zahavi (2005a, p. 144) suggests that patients ‘clearly recognize’ that the alien thoughts belong to them because they are the subjects in whom the alien episode occurs. First, here we observe again the confusion between a sense of subjectivity and a sense of mineness that underlies Zahavi’s whole argumentation. Second, we can still suggest what is retained is a sense of subjectivity and that the sense of mineness is missing. This is because Zahavi’s claim can be better interpreted as referring to an operation occurring at the level of attributions rather than referring to an actual experience of mineness. It is perfectly plausible to claim that I can recognize that P without having the actual experience of P. Zahavi seems to overlook the fact that self-attributions can be reached through judgements not necessarily grounded in first-order experiential information (Graham & Stephens, 2000). From this point of view, an attribution of mineness would not necessarily entail an experiential sense of mineness. All what is left in cases of thought insertion is a sense of subjectivity and a certain attribution of mineness as a reflective acknowledgement rather than a felt sense.
My suggestion is, in fact, entirely consistent with a broader phenomenological description of psychosis that Zahavi’s analysis seems to overlook. Psychotic patients usually report a conflict between things they know that have to be the case and the way things feel. As De Hann and De Bruin (2010, p. 385) observe:
166 First-onset schizophrenic patients often report that although they know that it is their body that is moving and realize that it must be their thought– after all, it is going on in their mind! – the utterly disturbing experience is that it just does not feel that way.
In some cases, psychotic patients seem to retain the ability to attribute certain mental states to themselves without these mental states enjoying an actual experiential sense of mineness. As a patient says: ‘I know it cannot be true. That would be nuts. But I feel that way’ (De Hann & De Bruin, 2010, p. 385). Psychotic patients show important discrepancies between the way they feel certain experiences and what they know about what has to be the case, and this seems to be one of the main sources of the conflicting character that pervades psychotic reports. In psychosis, the experience at the sense level and the knowledge at the attributional level run contrary to each other and Zahavi’s reply does not consider this. The claim that patients ‘recognize’ or ‘acknowledge’ that thoughts are their own does not guarantee the retention of an experiential sense of mineness in cases of thought insertion because patients seem to do this in virtue of an attribution.
When considering all the phenomenological and conceptual problems underlying Zahavi’s replies, it seems plausible to conclude that: (i) thought insertion is best characterized as a case where thoughts lack a sense of mineness and therefore, (ii) that it is phenomenologically possible for a self-aware subject to experience certain mental states not as her own mental states. Finally, this shows that a sense of mineness construed as an experiential feature of conscious experiences plays little role in explaining the subjectivity of phenomenal consciousness, at least, the minimal form that seems to be preserved in cases of thought insertion.
4. Concluding Remarks
Subjectivity theories of consciousness defend a necessary link between phenomenal consciousness and self-awareness (SCC). Among them, Zahavi’s self-presentational view (SPV) specifically maintains that such a link has an experiential reality. On this view, an experiential sense of mineness claimed to be intrinsic to all conscious experiences is a necessary condition for a subject to become self-aware. Thus, the most minimal type of subjectivity entailed by phenomenal consciousness would necessarily require an experiential sense of mineness to exist. This paper has shown that cases of delusions of thought insertion undermine this latter stronger claim. This is not to say that there is no connection between phenomenal and self-awareness; Rather, that Zahavi’s explanation for such a connection is unsatisfactory. Contrary to what the SPV claims, thought insertion is best understood as a case where self-aware subjects enjoy
167 phenomenal access to thoughts that are not experienced as their own thoughts, i.e. not having a sense of mineness. In this context, the replies offered by the advocates of the SPV are meant to defend the view that thought insertion involves the retention of a sense of mineness, and in this way, to defend the necessary role of the sense of mineness in grounding the connection between phenomenal and self-consciousness. Our analysis shows that although these replies introduce a number of interesting issues to the discussion, they cannot do their job properly because, apart from conflating a sense of subjectivity with a sense of mineness, they are based on implausible conceptualizations of both the phenomenology of thoughts and the notion of stream of consciousness.
Here, let me strengthen the general conclusions reached in this paper by appealing to the phenomenology of other psychotic cases. Thought insertion is not the only conscious episode where a sense of mineness might be lost. Take the case of depersonalization for example. These patients complain that their sensations and perceptions no longer feel as through they belong to them: ‘when a part of my body hurts, I feel so detached from the pain that it feels as if it was somebody else’s pain’ (Sierra, 2009, pp. 161-162). Sometimes, patients even describe themselves as a mere bunch of thoughts (Bayne, 2004). A depersonalization patient even reached the belief that he no longer existed (Strawson, 1997, p. 418). Along with cases of depersonalization, Cotard delusions, i.e. the delusional belief that one is dead (McKay & Cipolotti, 2007) also seems to provide phenomenological evidence against Zahavi’s idea that the sense of mineness is an experiential component intrinsic to all conscious experience. Contrary to what the SPV claims, Gerrans (2000) concludes that Cotard patients appear to have lost the sense of mineness taking this lack at face value.
Both, cases of depersonalization and Cotard delusion seem to reinforce the idea that it is phenomenologically possible for the sense of mineness and self-awareness to come apart. In these cases, patients are self-aware and undergo certain experiences without an experiential sense of mineness. Perhaps, the lack of sense of mineness in depersonalization cases is not as clearly observed as in cases of thought insertion. However, depersonalization in conjunction with thought insertion seems to clearly reduce the appeal of the SPV. Now, the case of Cotard delusion seems more diminishing. After all, what can be experientially owned in a mental life of a subject that feels that no longer exist? In these cases, there would not be a sense of mineness mainly because, experientially, there would be nothing to be owned! At least experientially, Cotard’s reports are best understood as referring to patients that do not feel an experiential sense of mineness for their own mental lives, without this implying that they cannot reach an attribution
168 of mineness. Here, I think that the observation of all these cases offers phenomenological grounds to distinguish between two kinds of conscious experiences. One the hand, fully-owned experiences would be those that enjoy a sense of subjectivity and an experiential sense of mineness, as in normal cases. On the other hand, plain experiences would be those that only enjoy a sense of subjectivity, as those that certain psychotic reports seem to instantiate. Certainly, this often overlooked distinction seems to be crucial to understand the way in which subjectivity theories of consciousness might be able to experientially link phenomenal consciousness with self-awareness.
Finally, from the observation of all these delusional cases, it seems well grounded to suggest that the sense of mineness – as understood by Zahavi – plays little role in explaining the most minimal form of subjectivity of phenomenal consciousness. All these cases are best interpreted as self-aware subjects that undergo certain conscious experience without an experiential sense of mineness. Importantly, this is not to say that the sense of mineness plays no role in explaining, perhaps, non-psychotic forms of subjectivity. Although a certain form of subjectivity is always preserved in psychosis, subjectivity as such is importantly diminished in these cases. Perhaps, an experiential sense of mineness plays an important role in making sense of less fundamental forms of human subjectivity such as a narrative or social self-awareness. The main issue is that, in light of the offered examination and the gaps in Zahavi’s replies, it is not entirely clear what role this might be. Thus, the specific role of an experiential sense of mineness in the task of understanding the different forms of human subjectivity remains an open question.
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172 Making Sense of the Adaptive Role of Psychotic Delusions
Summary
Beliefs can be psychologically adaptive mental states when they protect the subject from psychological threats or biologically adaptive when they help to increase a subject’s chances of survival within a specific environment. From this point of view, delusions are commonly regarded as maladaptive misbeliefs. While it is accepted that some delusions can be psychologically adaptive, it is usually denied that they can be biologically adaptive. In this paper I argue that there are good reasons to characterize a certain type of psychotic delusions as biologically adaptive. After distinguishing between two types of delusions and clarifying their relationship with the two modes of adaptiveness of beliefs I claim that in trying to make sense of the biological adaptive benefits of psychotic delusions, one needs to understand such phenomena in the general perceptual and affective context in which some of them are adopted. During the period that precedes the adoption of some delusional beliefs patients gradually lose their behavioural and psychological connection with the environment and this disconnection decreases the subjects’ chances of survival. However, in characterizing delusions, current dominant approaches fail to integrate this context into the aetiological picture of the phenomena missing the role that the adoption of some delusional beliefs might play in reorganizing the patients’ disunified and overwhelming (inner and outer) experiential world. Thus, the adoption of delusional beliefs might contribute in some cases to the preservation of behavioural and psychological interaction with the environment as an attempt – however pathological – to render the patients’ reality more predictable and approachable. Human cognitive systems would sacrifice doxastic accuracy in order to secure a minimally functional degree of interaction with the environment and therefore, certain psychotic delusions might be characterized as biologically adaptive under rarefied experiential circumstances.
An earlier version of this paper was presented at the Annual Conference of the British Psychological Society (Consciousness & Experiential Psychology Section), The University of Cambridge, UK.
Acknowledgments: I shall thank Prof Dr Thomas Fuchs, Prof Max Coltheart, Dr Matthew Broome, Dr Matthew Parrott, Dr Leo Tarasov, Dr Tom McClelland, and Dr Vaughan Bell for penetrating comments on earlier drafts of this paper. Special thanks go to Dr Roberta Payne whose first-person feedback was fundamental to develop my original proposal.
173 ‘extremis malis extrema remedia’
1. Delusions as Maladaptive Misbeliefs
Delusions are the hallmark of a disrupted mind; they are a crucial symptom of schizophrenia and a prominent feature of a number of other psychiatric and neurological conditions. The current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) defines the phenomenon as ‘a false belief based on incorrect inference about external reality that is held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary’ (American Psychiatric Association, 2013, p. 819). However, this definition is controversial in many ways. Some delusions might be characterized as accidentally true (Miyazono, 2015) and others might not even be about external reality but rather about internal mental or bodily states138. Sometimes, even the internal-external distinction becomes obscure as in the case of a patient that claimed to be at Boston and Paris at the same time (Weinstein & Kahn, 1955). Setting aside further discussions, the main purpose of this paper is to make sense of the potential adaptive role that certain delusions arising in the context of psychosis might play in the patients’ life. Here, I take delusions simply to be paradigmatic cases of misbeliefs, i.e. false beliefs or beliefs that are not correct in all particulars (McKay & Dennett, 2009, p. 493)139.
Advocates of the misbelief-formulation of delusions usually claim that true beliefs are per se adaptive while most misbeliefs are maladaptive140. However, such claim needs some refinement. In analysing the adaptive benefits of beliefs, authors draw a basic distinction between two different modalities of adaptiveness: psychological and biological adaptiveness (McKay & Dennett, 2009, p. 502; Bortolotti, 2014, p. 4). Authors employing these categories usually endorse a second distinction between two types of delusions depending of their psychogenesis: motivational and deficit-based delusions (Mckay, Langdon & Coltheart, 2009). Armed with this basic set of distinctions, advocates of the misbelief-formulation of delusions conclude that while motivated delusions can be characterized as psychologically adaptive for the role they play in protecting the self from psychologically threatening stimuli, delusional misbeliefs – in all their forms – play no role in enhancing the subject’s chances of survival, and therefore they cannot be
138 Take the case of Cotard delusion that involves the delusional belief that one is dead (McKay & Cicopolotti, 2007). Such delusional belief is not about external reality – as in the case of Capgras delusion for example - but rather about internal states of the subject. 139 For a further treatment of this view see the introduction to this compilation. 140 A further philosophical disagreement in this context is given by the discussion about what is a belief (see section 2).
174 biologically adaptive (Zolotova & Brüne, 2006; McKay & Dennett, 2009)141. Here, the claim is not that psychotic delusions are not subjectively desirable; negative emotions, such as anger or anxiety, might be not subjectively desirable, but they play an important role in increasing an individual’s chances of survival in her environment. Rather, the claim is that delusional beliefs play no relevant role in such task. The main argument for this position is that adaptation requires humans to approximate reality accurately and only true beliefs can perform this task appropriately. Thus, the beliefs that maximize the survival of the subject in a specific environment are necessarily those that best approximate reality by capturing true states of affairs in the world, i.e. true beliefs (Dennett 1971; Fodor 1983; Millikan; 1993). Beliefs that do not approximate reality in an accurate way cannot increase the believer’s chances of survival, and therefore delusional beliefs – as false beliefs – cannot be biologically adaptive.
Against some of these widespread presumptions in current neurocognitive research on delusions, this paper argues that it is possible to characterize a specific type of psychotic delusions as biologically adaptive under certain circumstances. Certainly, from an adaptive point of view, having true beliefs is always better than having delusional misbeliefs as approximating reality in a more accurate way will always lead to better adaptation to the environment. However, biological adaptiveness should not be understood as an absolute notion, but rather, as a matter of degree and only in reference to a particular environment142. From this point of view, the arguments for the claim that true beliefs are always preferable do not establish the case for the total lack of biological adaptiveness of delusional misbeliefs. One might even say that the doxastic accuracy that usually accompanies paradigmatic true beliefs can come apart from survival under special circumstances (see Stich, 1990). Therefore, as we will see, there might be more than one way of understanding the notion of biological adaptiveness.
Based on these ideas, in section 2 I first clarify the two basic modes of adaptiveness of beliefs and examine the relationship between them and two different ways of characterizing delusions in virtue of their psychogenesis. In section 3 and 4, I claim that in trying to make sense of the adaptive benefits of psychotic delusions, one needs to consider the perceptual and affective context in which some of them emerge. It is noted that the period that precedes the adoption of some delusional beliefs in psychosis is characterized by a phenomenologically overwhelming and disunified affective and perceptual experience of the patient’s inner and outer world (Fuchs,
141 In this paper I assume a very basic notion of biological adaptiveness: for a mental state M (of a subject S) to be biologically adaptive, M needs to increase S’s chances of survival in S’s environment. I clarify this issue in section 2. 142 For example, paranoia might be not adaptive in friendly environments; however, it might be adaptive in environments with high risks of violence. I thank Dr Bell Vaughan for pointing out this issue.
175 2005; Van Rossum et al., 2011; Ratcliffe, 2013; Marhawa et al. 2013). During this pre-delusional period, patients would tend to gradually lose their behavioural and psychological connection with the environment and such disconnection would decrease the subjects’ chances of survival. Problematically, current dominant approaches fail to integrate these contextual alterations in their analysis of the potential benefits of some psychotic delusions, missing the role that the adoption of delusional misbeliefs might play in reorganizing the patients’ disunified experiential world in these circumstances.
I suggest that, on certain occasions, the human cognitive system sacrifices some degrees of doxastic accuracy in order to secure a minimal functional level of interaction with the environment. So, even if delusions emerge as the result of different impairments in the process of formation of beliefs – as the misbelief-formulation of beliefs claims – the adoption of delusions might sometimes contribute to the preservation of behavioural and psychological interaction with the environment as an attempt – however pathological – to re-establish some of the broken aspects of consciousness that seem to be at the basis of the general state of confusion that characterizes this period. In the absence of clear doxastic inputs, the adoption of delusional beliefs – even if false – might be the only available functional way to make reality more approachable, increasing the patients’ chances of survival in such extraordinary experiential circumstances. This would suggest that beliefs might be adaptive in virtue of their veridical content (true beliefs) or in virtue of the role they play in dealing with phenomenologically confusing and overwhelming situations (some psychotic delusions). This is by no means to say that delusions are preferable to true beliefs, but rather that in such rarefied contexts, the adoption of delusions would make the patient more likely to survive. Finally, in section 5, I conclude with some reflections on the scope of my proposal and its practical implications in the context of the treatment of delusions.
2. Mapping the Debate: Modes of Adaptiveness and the Types to Delusions
How could it ever be adaptive to believe a falsehood? And more specifically, how could a misbelief aid survival? Before answering these questions, we need to get clear on the relationship between two crucial distinctions on which our discussion rests, namely, that (a) there are two basic ways in which beliefs of any kind can be adaptive and (b), there are two main types of delusion distinguished on the basis of their aetiology.
176 2.1. Modes of Adaptiveness of Beliefs
The debate about what is a belief is still open (Schwitzgebel, 2015). Most contemporary philosophers view beliefs simply as propositional attitudes143. In what follows, I take beliefs to be mental states of a subject that implement or embody that subject’s endorsement of a particular internal or external state of affairs as actual (see McKay & Dennett, 2009, p. 493). There are two modes in which beliefs can be adaptive:
2.1.1. Psychological Adaptiveness
For a certain belief B of a subject S to be psychologically adaptive, B needs to help S to deal with – and desirably overcome – psychologically problematic internal or external stimuli. Broadly construed, a psychologically problematic stimulus is any stimulus that might threaten S’s self-esteem, self-image, and self-related representations of the world144 (see Bentall et al. 2001). Here, beliefs are aimed to protect the ego from unbalances in its self-representation mainly through the management of strong negative emotions or conflicts. For example, the belief ‘Everything happens for a good reason’ might help a subject to deal with an overwhelming feeling of powerlessness which is, in turn, a threat to the subject’s self-esteem and self-image. Psychologically adaptive beliefs are common in the normal population, as they help us to deal with some problematic aspects of our everyday psychological life (Bentall, 2003). Psychologically adaptive beliefs are not necessarily delusive or self-deceptive. They do not necessarily involve impairments in the machinery in charge of the process of formation of beliefs. However, a failure in this machinery might cause these states to turn into delusions or pathological self-deceptive beliefs (Bayne & Fernández, 2009).
2.1.1. Biological Adaptiveness
For a certain belief B of a subject S to be biologically adaptive, B needs to increase S’s chances of survival in P’s environment. Often, biological adaptiveness is seen as more fundamental than psychological adaptiveness. However, there are no clear reasons to suppose these two modes of adaptiveness are not functionally related in some way. True beliefs are usually taken as biologically adaptive, for they allow a subject to apprehend her environment in
143 Roughly speaking, a proposition is whatever a declarative sentence expresses. A propositional attitude is the mental state of having a certain attitude or stance towards a certain proposition. Hoping, desiring, wanting, and believing are different instances of propositional attitudes, among many others. 144 By self-related representations I mean any representation of a certain entity of state of affair involving a value judgement or an affective valence for a subject S. Examples of this are beliefs of the type ‘my family is morally good’, ‘my wife is kind and trustworthy’, ‘my son is a good student’, and so on. Arguably, in many cases these beliefs imply some functional degrees of self-deception.
177 an accurate way. In turn, this doxastic accuracy would enable humans to act effectively in the world, thus increasing adaptation (Millikan, 1993). Biologically adaptive beliefs are those beliefs that permit the subject to preserve a functional degree of mental and behavioural interchange with the environment. From this point of view, it is always better to have true beliefs than false beliefs, for true beliefs allow us to act effectively in our environments based on more precise doxastic information.
2.2. Two Types of Delusions
The second distinction that underlies our discussion is about two types of delusions. Delusions can be motivated or deficit-based in virtue of their psychogenesis. This distinction is crucial because different views on this issue lead to different understandings of the potential adaptive benefits of delusions in a patient’s life (see section 3) (Martens, 2002; Mckay, Langdon & Coltheart, 2009).
2.2.1. Motivated Delusions
Delusions are motivated when they emerge driven by the psychological benefits they confer to the deluded (Bortolotti, 2014). On this view, delusions arise as active psychological responses to highly disturbing mental conflicts that would otherwise lead to depression and protect against negative self-representations that would otherwise lead to low self-esteem (Bell, 2003). Thus, motivated delusions prevent loss of self-esteem and help manage strong negative emotions (Bentall, 1994; Ramachandran, 1996). Roberts (1992) claims that delusional phenomena would allow patients to incorporate highly negative experiences within their personal psychological framework. Thus, delusions are characterized as a defensive reaction to protect the self from psychologically relevant threats (Bentall et al. 2001; Pavlickova et al. 2013)145. Motivational approaches see delusions as a way of dealing with certain overwhelmingly conflictive situations146. As McKay, Langdon and Coltheart (2009) claim about motivational approaches, ‘a delusion constitutes a mental dexterous “sleight of mind”, a psychological
145 One proposal along these lines is Bentall and colleagues’ model of persecutory delusions (Bentall et al. 1991). On this motivational approach, persecutory delusions are the result of psychological mechanisms that are aimed to maintain the patient’s self-esteem when certain events highlight radical discrepancies between negative self- perceptions and self-ideals. Persecutory delusions on this account have an adaptive role for they re-establish the patient’s mental homeostasis, which has previously been diminished by problematic stimuli. 146 From a motivational framework, Butler (2000) claims that some delusions might emerge as a meaning-giving strategy, i.e. as an attempt to make sense of a catastrophic loss or feeling of emptiness. Butler even suggests that some delusions might protect patients from intolerable feelings of depression after traumatic episodes. Finally, Martens (2002) suggests that delusional systems constitute routes to remission; they allow the temporary avoidance of an unbearable aspect of the patient’s reality; after the patient’s circumstances become favourable, they are ready for healthy development and remission (p. 503).
178 manoeuvre effected to maintain psychic integrity and reduce anxiety’ (p. 166). One of the most famous examples of motivational approach in the history of psychiatry is the so-called psychodynamic tradition. Sigmund Freud – the main advocate of psychoanalysis – suggested that: ‘a delusion is found applied like a patch over the place where originally a rent had appeared in the ego’s relation to the external world (1924/1986, p. 565). On this view, delusions emerge as a conscious way of dealing with profound unconscious affective and sexual conflicts. However, such view has been regarded as implausible by a number of authors (Ramachandran, 1995; Stone & Young, 1998; Ramachandran & Blakeslee, 1998).
2.2.2. Deficit-Based Delusions
The currently dominant view in the literature characterizes delusions necessarily as the result of different functional impairments at different stages of the process of belief and thought formation (Maher, 1977; Ellis & Young, 1990; Coltheart, 2002; 2015). As Mckay & Dennett (2009) suggest:
If we conceive of the belief formation system as an information processing system that takes certain inputs (e.g., perceptual inputs) and (via manipulations of these inputs) produces certain outputs (beliefs, e.g., beliefs about the environment that the perceptual apparatus is directed upon), then these [delusional] misbeliefs arise from dysfunction in the system – doxastic dysfunction. Such misbeliefs are the faulty output of a disordered, defective, abnormal cognitive system (p. 496).
This view of the formation of delusions emerges in the context of neuropsychiatric research. This approach (i) is focused on the development of empirically informed models of the processes involved in normal belief formation and evaluation, and (ii) aims to explain delusions in terms of damage to one or more of these processes. Rather than ‘sleights of the mind’, on this view delusions involve disorders and disruptions in the normal functioning of beliefs produced by a combination of, among many others, anomalous first-order perceptual experiences (Maher, 1974), first-order perceptual experiences accompanied by negative feelings of strangeness (Synofzik, Vosgerau & Newen, 2008), impairments in the process of hypothesis evaluation (Langdon & Coltheart, 2000), or unusual experiences accompanied by reasoning biases (Garety et al. 2001).
179 2.2.3. Motivated or Deficit-Based Delusions?
The two aforementioned formulations of delusions represent two different traditions in research in psychiatry. The contrast between these two can be better understood in light of their interpretations of the same delusional phenomenon. Let’s take Capgras delusion, i.e. the delusion that a close relative (spouse for example) has been replaced by an impostor. Enoch and Trethowan (1991) offer a motivational explanation of this delusion and claim that it arises to solve an affective conflict faced by subjects that experience ambivalent feelings towards a close relative: on the one hand, feelings of love and affection and, on the other hand, disturbing feelings of hate and aggression147. Through the adoption of the delusional belief, patients are able to express this unacceptable affective state, avoiding the guilt that would follow from the expression of such feelings towards a beloved person.
On this interpretation, Capgras delusion is developed by the patient to reduce the tension produced by the conflict of having ambivalent and conflictive feelings towards a beloved person. In contrast with this interpretation, deficit accounts claim that Capgras delusion arises as the result of impairments in the affective component of face recognition (Ellis & Young, 1990; Stone & Young, 1998). Face-recognition is composed of two components, a ‘pattern-matching’ component and an emotional component (limbic system) that provides the so-called experience of ‘familiarity’ when encountering a close relative. When the connection between these systems breaks down, subjects experience incongruences between the way someone ‘look’ and the way they ‘feel’, this experience leading to the adoption of the delusive belief (Langdon & Coltheart, 2000). Although Davies et al. (2001) identify two routes from abnormal experience to the delusional belief itself, the main idea that underlies this approach is that delusions are the product of faulty mechanisms involved in the process of belief formation and evaluation.
There is an ongoing debate about the way we should think of the relationship between these two traditions. Some people think of them as two equally plausible alternatives to explain pathological phenomena with necessarily distinct origins. The idea is that some delusions might not be explained in terms of deficits in any portion of our mental architecture (Butler, 2000). Rather, delusions can be explained in terms of the proper functioning of certain defense mechanisms originally meant to protect the self (Freud, 1924/1986; Roberts, 1992). However, at the present stage of empirical research on the formation of delusions, such a view does not seem
147 Endorsing an explicitly Freudian formulation of delusions, Capgras & Carette (1924) claim that such ambivalence is originated in the patient’s attempt to mask unconscious incestuous feelings towards her relative.
180 plausible and most researchers accept that all delusions might imply at least some deficit at different levels of the process of formation of beliefs. So, even if some delusions were motivated, their aetiological route would also imply certain impairments in the machinery in charge of forming beliefs148.
Here, it is important to note that aetiological functions and psychological comfort are not necessarily tied together and that they can come apart. For example, pain and negative emotional states are psychologically negative but they are the result of a well-functioning aetiology. Perhaps, pain and negative states serve the important adaptive role they play precisely because they are psychologically negative. As Miyazono (2015) claims ‘pain would fail to defend the body if it were psychological positive’ (p. 568). The reverse case is also possible. There are some states that can be understood as psychologically positive, but aetiologically malfunctional. Nesse (1998) observes that low levels of anxiety – that are psychologically positive – are aetiologically malfunctional. Anxiety has a crucial adaptive role and insufficient levels of anxiety would imply a failure in performing this role properly.
Taking all these issues into consideration, the most prominent version of the deficit formulation of delusions is the two-factor view (see Coltheart, Langdon & Breen, 2001, among many others). As Aimola, Davies and Davies (2009) claim, this view seems to be able to make sense of most delusions from a conceptually and empirically well-informed framework. Broadly speaking, on this view, delusions are rooted in abnormal experiential inputs resulting from different impairments (factor 1). This factor is meant to explain where the delusion experientially comes from. However, the presence of the anomalous experience is not itself sufficient for the formation of the delusional misbeliefs (Davies et el., 2001). In contrast to one-factor views – another popular deficit approach where delusions are seen as reasonable hypotheses, given the strange character of the abnormal first-order experience (Maher, 1974) – two-factor advocates propose a deficit in the system of belief evaluation (factor 2) to explain the routes from some abnormal experiences to certain delusions, i.e. a deficit with the assessment of the evidence for and against the delusional belief149. This second factor is meant to explain how certain delusional beliefs are adopted and maintained over time. Thus, by the introduction of a second factor involved in delusion formation, the two-factor view overcomes the difficulty that one-factor
148 The challenge is to establish a well-grounded connection between these different underlying impairments and the ‘motivational’ nature of the antecedents of the delusional belief itself, but I cannot analyse this issue further here. 149 An additional debate in this context is whether the adoption of the delusional misbelief arises as a mere endorsement of the content of the abnormal experience (factor 1) or as an explanation for a factor-1 anomalous experience with vague content (see Davies, Coltheart, Langdon & Breen, 2001; Pacherie, Green & Bayne, 2006; Sollberger, 2014).
181 views have in explaining why there are people with experiential impairments that do not develop delusional beliefs (Langdon & Coltheart, 2000).
3. Doxastic Deficits and the Adaptiveness of Delusions
Having refined the distinctions that underlie our discussion, let’s now come back to the target issue of this article, i.e. whether delusions can be biologically adaptive. In the case of motivated delusions (section 2.2.1.), it is claimed that the adoption of the delusional belief emerges as a defensive strategy that provides mental relief through the overcoming of external or internal psychological threats to the patient’s mental well-being (see Bortolotti, 2014). Therefore, by definition on the motivational accounts, delusions are psychologically adaptive. This psychologically beneficial role seems to be tied to the very aetiological architecture of these delusions. Advocates of the misbelief-formulation of delusions have no problems accepting such a claim for they explicitly recognize that motivated delusions might facilitate the negotiation of overwhelming circumstances by enabling the management of, for example, powerful negative emotions (Mckay & Dennett; 2009, p. 502). In addition, the advocates of the misbeliefs formulation of delusions might also suggest that even if we can conceive of some delusions as psychologically adaptive, this does not imply they are not caused by any deficit. Perhaps, the positive psychological nature of these delusions can be characterized as a secondary positive outcome of a doxastic deficit (see section 2.2.3; López-Silva, 2015), or as the reason why delusions persist150. Thus, it is not controversial to accept that motivated delusions might serve a psychologically adaptive function in extraordinary circumstances.
However, in their analysis of the benefits of different misbeliefs, McKay and Dennett (2009) make two remarks about delusions: first, that the only type of delusional misbelief that can be adaptive are those misbeliefs that have motivational nature. Second, the authors point out that motivated delusions can only be psychologically adaptive. The claim here is that, while it might be argued that some delusions can be psychologically adaptive in certain scenarios, this does not establish the case for biological adaptiveness, for one should distinguish human happiness from biological fitness (p. 502). Although some delusions can be psychologically adaptive, they would not be tied to biological survival in any sense and therefore, no delusion is biologically adaptive151.
150 I thank Matthew Parrott for suggesting this point. 151 In fact, the authors conclude that the only type of misbelief that can be adaptive in this last sense is positive illusions, namely, ‘biased perceptions that give rise to a belief that departs from reality’ (Taylor & Brown, 1988, P.
182
The main argument for this conclusion has been already introduced in section 1 but it would be useful to rehearse it here. McKay and Dennett (2009) claim that humans are biologically designed to form true beliefs and that therefore true beliefs represent an evolutionary tool that enables humans to act effectively in their world; true beliefs are devices originally meant to successfully adapt to the environment, while false beliefs – like delusions – impair this task. The authors claim that successful adaptation requires an organism to approximate reality accurately. Thus, only true beliefs might successfully help an organism to adapt to her environment. The beliefs that maximize a subject’s survival are necessarily those that best approximate reality by capturing true states of affairs in the world (Dennett 1971; Fodor 1983; Millikan; 1993). Delusions would imply impairments in a cognitive system originally meant to enable humans to act affectively in their environment through the production of true accurate beliefs. In addition, if delusions are the product of different impairments associated with the normal functioning of the process of belief and thought formation, they cannot be biologically adaptive for they diminish successful adaptation (p. 502). However, it seems to be that the conclusion that delusions cannot be biologically adaptive does not follow for a number of reasons.
First, it is not clear why psychological adaptiveness would not be in any way associated with biological adaptiveness. Such a sharp distinction is not something that should be taken for granted, for it seems plausible to think that, at least in humans, the development of certain psychological abilities – such as psychological defences – might increase the chances to biologically adapt to the environment (Beresford, 2012). Therefore, it may be that defending the self from psychologically threatening stimuli does not just bring psychological comfort, but also reproductive success for instance. It is true that the case for the relationship between psychological and biological adaptiveness needs to be further argued, but it look like plausible idea152. When humans are stressed and under unfavourable affective conditions, they find ways to cope and this helps them to survive, as Beresford (2012) points out, ‘the ultimate goal of successful psychological adaptation is to increase adaptive options to include the most flexible, creative, and therefore most effective actions available to any single person at any given point in time’ (p. 1). It seems highly plausible that, sometimes, psychological adaptiveness involves some
194). These misbeliefs would include unrealistic positive self-evaluations, exaggerated perceptions of personal control or mastery, and unrealistic optimism about the future, among many others. 152 The exploration of this issue might add important elements to our discussion but I cannot develop this point further here. For a discussion on this issue, see Taylor and Brown (1994).
183 degree of biological adaptiveness. However, it is important to note that the opposite is not necessarily the case; something that increases a subject’s chances of survival does not necessarily help to protect the subject’s self-esteem or self-image (see section 4).
Second, the concept of adaptation that underlies the authors’ proposal seems overly simplistic. As said before, adaptation is not an absolute notion, but comes in degrees and depends on the analysis of the specific environmental circumstances of a subject. One can uncontroversially claim that an organism S is better adapted than an organism O to the same environment without implying that O has not successfully adapted to such environment. Perhaps, one might say that S’s adaptation is more successful than O’s as S chances of survival are higher than O’s. However, this does not imply that O has no chances of survival, and one should examine O’s case in light of a notion that respects the idea that adaptation comes in degrees. Therefore, even if delusions are not as adaptive as true beliefs, it does not necessarily follow that delusional beliefs are not biologically adaptive at all. True beliefs would maximize adaptation, but this does not mean that delusions play no biological adaptive role.
Finally, and more importantly, there seem to be good reasons to think that, even if delusions are the product of different impairments, they might still be biologically adaptive, and that doxastic accuracy can come apart from biological adaptation under certain circumstances. Taking all these aspects of the discussion into consideration, in the following sections I explore some of the reasons to resist McKay and Dennett’s conclusion on the biological adaptive role of deficit-based misbeliefs. I argue that if we include the affective and perceptual context in which delusions occur in their aetiological picture, such phenomena can be seen as biologically adaptive on the basis of the role they play in preserving a minimal degree of behavioural and psychological interaction with the environment.
4. Making Sense of the Adaptive Role of Delusions: A proposal
4.1. The Context of Delusions
In line with what is suggested by McKay and Dennett, Zolotova and Brüne (2006) claim that the bizarre content of delusional beliefs can be interpreted as a pathological variant of a system that it is primarily meant to adapt the subject to the environment and therefore delusions cannot be beneficial in any way. Certainly, if we focus our attention on the bizarre nature of the specific delusional contents that patients report, it is quite natural to conclude that they cannot be – or at least, they do not look – beneficial at all. How can it be beneficial for a patient to have the
184 belief that aliens are placing rules into her mind? (Payne, 2013) or to have the belief that one is dead? (McKay & Cicopolotti, 2007). Prima facie, such bizarre beliefs look too disturbing and far too removed from reality to be biologically adaptive, namely, to promote functional interaction with the environment in order to increase the subjects’ chances of survival.
However, this conclusion seems too quick and it seems to be based on a excessively narrow approach to the aetiology of delusions that overlooks the complex phenomenological context in which some of them occur153. Psychotic delusions are complex phenomena that, most of the time, do not emerge out of the blue; rather, they are preceded by a number of intense affective and perceptual alterations that have often been overlooked by deficit approaches in their characterization of the phenomenon (Sass, 1992; López-Silva, 2015)154. These disruptions in affectivity and perception lead to a pre-psychotic fragmented and confusing phenomenological experience of the world and oneself that can last for days, months, or even years (Conrad, 1958; Jaspers, 1963; Ratcliffe, 2013; Payne, 2013). As Payne (2015) claims:
In the months preceding it [one of her delusional episodes], I experienced unreality many times. I had short periods of time in which I felt like I didn't exist. I had other experiences in which I had to, for instance, touch a coffee table in front of me to make sure it was real. I had short times in which nothing outside myself seemed to exist (unpublished interview).
In the rest of this section, I briefly explore these neglected alterations in affectivity and perception to finally claim that, when they are integrated into their aetiological picture, some psychotic delusions might be conceived as biologically adaptive (section 4.2.).
4.1.1. Pre-Delusional Affectivity and the Formation of Delusional Beliefs
Prior to the adoption of delusional beliefs, many patients experience a number of affective alterations that colour their entire experience of the world and themselves with an overwhelming, and most commonly, negative character (Gibbs; 2000; Fuchs, 2013). Although it is true that the affective performance of patients is affected by the stress associated with
153 It is important to note that my proposal will be confined to delusions arising in the context of psychosis. 154 In his masterpiece, General Psychopathology, Jaspers (1963) consider the delusional context in which some delusions emerge as one of the marks of psychotic delusions. However, it is important to note that not all delusions emerge in such context as, for example, those arising as the result of brain damage. My proposal will be confined to psychotic delusions arising under these circumstances. I thank Max Coltheart and Matthew Parrott for stressing this point.
185 delusional phenomena (post-delusional consequences), there is sufficient evidence to claim that pre-delusional affective deficits are crucial in the psychogenesis of delusions (Strauss et al. 2013; Marwaha et al. 2013; Maiese, 2014). While deficit approaches have stressed the former idea, they have largely ignored the latter (Mckay, Langdon & Coltheart, 2009; Skodlar et al. 2012).
Different dimensions of affectivity are impaired in the period preceding the emergence of delusions. Strauss et al. (2013) suggest that pre-psychotic affective instability might lead to the occurrence of certain psychotic symptoms, such as delusions and hallucinations. Patients that develop psychotic symptoms usually show pre-psychotic mood instability. Broome et al. (2005) and Broome et al. (2012) report high rates of anxiety and depressive states among people at risk of psychosis prior to the occurrence of relevant psychotic episodes. In the same vein, it has been shown that anxiety and depressive experiences are crucial elements in the process of the formation and persistence of some psychotic states, such as auditory hallucinations (Bentall et al. 2001; Freeman et al. 2002). This reported vulnerability to psychosis produced by anxious and depressive moods involves an enhanced hypothalamic pituitary axis response to stress which in turn increases patients’ general reactivity to negative stimuli (Aiello et al. 2012). Kramer et al. (2013) suggest that this enhanced reactivity may produce a general state of affective instability in the patient that, in turn, may lead to the development of certain psychotic symptoms. This is consistent with a number of different empirical studies that report that schizophrenic delusions often arise in the general context of negative affectivity (Buckley at al. 2009; Van Rossum et al., 2011; Strauss et al. 2013). Interestingly, Kramer et al. (2013) conclude that the temporal fluctuation that characterizes the occurrence of psychotic symptoms like delusions may be the result of fluctuations in the patients’ affective performance derived from these pre-delusional affective impairments155.
All these disturbed dimensions of affectivity seem to have a crucial doxastic role in the psychogenesis of some delusions, given the general role they have in the process of belief and thought formation (O’Driscoll, Laing & Mason, 2014). More important for our analysis is the fact that all these dimensions manifest themselves subjectively in the patient’s life as an intense, overwhelming, confusing, and stressful affective experience of the world and themselves leading – in conjunction with other deficits – to the adoption of delusional beliefs (López-Silva; 2015). A study conducted by Marwaha and colleagues (2013) identifies a robust link between this affective instability and psychotic symptoms, concluding that affective instability may predict
155 It is important to note that here I’m not claiming that these conditions in affectivity are sufficient for the occurrence of delusions, but rather, that all these deficits in affectivity play a crucial role in the process of formation of beliefs.
186 the emergence and maintenance over time of certain delusions. Therefore, there are good reasons to think that delusions emerge in the context of general affective changes that affect the experience of the world and oneself, giving it a negative character. Specifically, Marwaha et al. (2013, p. 6) claim that ‘the sense that emotional experiences are out of one’s personal control may prompt a search for meaning that may find explanations in terms of external influence’156.
4.1.2. Delusional Moods and Delusional Beliefs
The period prior to the adoption of some psychotic delusions is not only characterized by a number of affective changes but also by a ‘transformation in our total awareness of reality’ (Jaspers, 1963, p. 97). Some delusions emerge in the context of a general phenomenological transformation of the way patients perceive the world. During this period:
Patients feel uncanny and that there is something suspicious afoot. Everything gets a new meaning. The environment is somehow different –not to a gross degree- perception is unaltered in itself but there is some change which envelops everything with a subtle, pervasive and strangely uncertain light. A living-room which formerly felt as neutral or friendly now becomes dominated by some indefinable atmosphere. Something seems in the air which the patient cannot account for, a distrustful, uncomfortable, uncanny tension invades him (Jaspers, 1963, p. 98).
This prodromal period is usually referred as delusional mood or delusional atmosphere and it may last for days, months, or even years (Conrad 1958; Jaspers, 1963; Fuchs, 2005). This state reflects a change in the way the world is encountered by patients (Ratcliffe, 2013); in contrast with normal cases, during delusional moods perception is only capable of giving a superficial phenomenological impression of objects, which are experienced by patients as an unreal appearance or a staging (Fuchs, 2005, p. 136). ‘Everything is strange, or everything is somehow different’, a patient says (Sass, 1992, p. 46). The environment becomes an alien, puzzling, and mysterious place. A patient claims that ‘wherever you are looking, everything looks unreal’ and that ‘people went down the street like in a puppet theatre’ (Gross & Huber, 1972). Another patient claims that ‘when you go somewhere, everything seems already set up for you like in a theatre – it’s really, eerie, and you get terribly frightened’ (Fuchs, 2005, p. 134). Given that reality presents itself as different from what was expected, patients are no longer capable of
156 Interestingly, this suggestion is consistent with the phenomenology of some of the most severe delusions in schizophrenia, such as thought insertion and delusions of alien control (see Mullins & Spence, 2003; Pacherie, Green & Bayne, 2006).
187 predicting it. During delusional moods, patients no longer trust their experience of the world (Fuchs, 2005). However, this feeling of general uncertainty not only pervades the general experience of reality, but also specific objects in the field of awareness (Freedman & Chapman, 1973). In consequence, patients start experiencing an increasing oppressive tension, and general feelings of uncertainty, disunity, and lack of control spreads all over their experiences of the world and their own mental life (Conrad, 1958; Mishara, 2010).
The phenomenological changes in perception that characterize delusional moods have been associated with significant alterations in brain functions (Fusar-Poli, Allen & McGuire, 2008), structure (Fusar-Poli et al. 2012), and neurochemistry (Fusar-Poli et al. 2011). Dysregulation of dopaminergic neurotransmission is one of the most robust neurobiological findings in psychosis, with an average elevation of 14% in patients compared with controls (Fusar-Poli et al. 2013). This increased subcortical dopamine activity is already present before the full expression of psychotic symptoms, such as delusions. Therefore, longitudinal elevation in striatal dopamine synthesis can be specifically linked to the context of the emergence of psychotic symptoms (Howes et al. 2011). Importantly for our discussion, it is suggested that these neurobiological alterations express themselves subjectively as disruptions in the process of binding of perception, agency and the self (Kapur, 2003). Arguably, these alterations would underlie the fragmented, confusing –and even chaotic- perceptual experience of the world and oneself that characterizes the period that precedes the adoption of delusional beliefs.
4.2. Delusions as Biologically Adaptive Misbeliefs
The misbelief-formulation of delusions accepts the idea that motivated delusions are psychologically adaptive in virtue of the role they play in defending the self from psychologically threating stimuli (section 2.2.1); however, it also claims that delusions – in all their forms – cannot be biologically adaptive because they do not contribute in any way to increasing the chances of survival of a subject in her environment (section 3). In this section, I argue that, when considering the different alterations that characterize the period preceding the adoption of some delusional beliefs, delusions might be characterized as biologically adaptive in virtue of the way they allow the reorganization of the patient’s experiential world and the way they allow the reincorporation of the true beliefs into the subject’s mental world.
In remaining alert to danger, sources of nourishment, and reproductive opportunities, humans try to maintain a stable and predictable psychological and behavioural contact with their environment. In this context, sharing an intersubjective world with other humans not only
188 facilitates the maintenance of healthy and adaptive psychological interactions, but also promotes biologically adaptive instances (Guidano, 1991; Beresford, 2012). Problematically, the many alterations in affectivity and perception highlighted in the previous sections seem to disrupt this interaction with the environment, decreasing the subject’s chances of survival. In contrast with their manifestation in non-pathological cases, phenomenal consciousness, self-consciousness, and consciousness of others in psychosis manifest themselves as very confusing and deeply fragmented states (Uhlhass & Silverstein, 2005). The unity and coherence of the affective and perceptual experience of the patient’s inner and outer world breaks down; this experience becomes gradually incoherent, disconnected, and disharmonious157.
During this period, selective attention is also affected and is drawn towards irrelevant stimuli, thoughts, and contingent artificial connections, leading to a distressing and highly unpredictable experience of the subjective, physical and social world (Kapur, 2003; McGhie & Chapman, 1961; Uhlhass & Mishara, 2007). The general feelings of uncertainty and lack of control that pervade the different dimensions of patients’ consciousness gradually lead them to lose their behavioural connection with the environment. During this period, physical and mental objects do not invite any type of activity (Ratcliffe, 2013); patients stop experiencing themselves as the agents of their own mental and physical lives and a feeling of practical disengagement and passivity progressively pervades their experience of the world and themselves (Sass, 1992; Wegner, 2004). However, this period is not only characterized by a gradual loss of behavioural connection with the environment, but also by a progressive loss of psychological connection with the intersubjective world158.
Human beings do not only inhabit a shared physical world but also a world of socially shared meanings of different complexity associated with the objects of one’s awareness. The manipulation of these shared meanings seems to be an adaptive advantage. A simple case of this is the associations we might make with a chair; a chair is not a mere physical object, it is something I can sit on, something I can use to have a rest after a long walk, and so on. A book is not just a pile of paper, but also something I can read, and so on. Here is a more complex case: when I hear an ambulance siren, the noise is not just a noise; it means that there is an emergency going on, that some people are in danger, and so on. In other words, the objects of one’s
157 There is substantial phenomenological and experimental data confirming that the patients’ subjective world is experienced as importantly fragmented and disorganized (see: Doniger, Silipo, Rabinowicz, Snodgrass, & Javitt (2001) and Keefe & Kraus (2009). 158 In fact, it seems plausible to suggest that this loss of psychological connection is at the root of the mentioned loss of behavioural connection with the environment. However, here I shall avoid this causal claim and I will treat these two types of connections separately.
189 awareness perception mean something for us, as it were, and this is part of our shared intersubjective world (Stanghellini, 2004). However, in the midst of the confusing and unpredictable experience of inner and outer reality that precedes the adoption of delusional misbeliefs, physical and mental objects seem to gain random and peculiar meanings: ‘the sight of a limping man on the street may suddenly evoke the impression of the devil hunting the patient [...] the stroke of a bell may announce his imminent death (Fuchs, 2005, p. 134), and so on. In this period, patients lose the familiar meanings of the perceived objects and situations and this leads to a fundamental disruption of the phenomenological constitution of the patient’s intersubjective world. Patients feel like they are in a foreign country unable to grasp the shared language and social meanings of their new community (Klosterkötter, 1988). The upshot of all these changes is that patients gradually lose the feeling of inhabiting a shared intersubjective world (Ratcliffe, 2013)159.
It is important to note that the change in the meanings associated with perceived objects does not add any certainty to the patients’ experience of the world and themselves. This is because these new meanings are also experienced as changing. For example, the stroke of a bell may announce an imminent death, the advent of God, or something else. During this period, objects are experienced as having multiple contingent meanings. In strict relationship with this last issue, during this period patients start experiencing an increased need for closure (Mishara, & Fusar-Poli, 2013). Kruglanski defines this notion as ‘the desire for a definite answer on some topic, any answer compared to confusion and ambiguity [will do]’ (1989, p. 14). Perhaps, this need for closure is a cognitive consequence of the series of changes in affectivity and perception highlighted in section 4.1. McKay, Langdon and Coltheart (2007) have shown that delusion- prone subjects score considerably higher than healthy controls on the Kruglanski, Webster and Klem’s need for closure scale.
During the period preceding the adoption of delusional beliefs, patients feel a higher need to resolve the all-pervading feeling of uncertainty and unpredictability of the world by grasping on anything that can make sense of the general state of phenomenological confusion and uncertainty they are undergoing. Using a two-factor deficit framework (see section 2.2.3.), it is suggested that one of the elements that distinguishes deluded from non-deluded subjects with aberrant experiences is an increased need for closure that might lead to a jumping-to-conclusions
159 It is possible to link this idea with the claims defended in paper 1 and 2 of this compilation regarding the formation of delusions of thought insertion. Following the picture mentioned in the text, apart from the affective conditions analysed in paper 4, these perceptual disturbances would be another important condition for the change in the affordances of our phenomenally available thoughts.
190 data-gathering bias (Colbert & Peters, 2002; Colbert, Peters & Garety, 2006). In consequence, subjects with highly disruptive affective and perceptual anomalous experiences that go on to adopt delusional misbeliefs may do so because they are cognitively motivated to explain such experiential states as a way of dealing with this increased need for closure. Thus, the resulting adoption of delusional beliefs ‘allegedly satisf[ies] a high need for closure, at the expense of doxastic accuracy (McKay, Langdon & Coltheart, 2007, p. 364).
As we can see, before some delusional misbeliefs are adopted in the context of psychosis, a number of things happen in the patients’ phenomenal field, and in order to understand how delusions can be adaptive, these alterations need to be taken into account. As said earlier, the task of determining the adaptive role of delusions necessarily involves the appraisal of the context in which they occur. Before adopting delusions in the context of the aforementioned affective and perceptual alterations, patients gradually lose their psychological and behavioural interactions with the environment and as a consequence their chances of survival decrease. Given the patients’ increased need for closure, delusions would arise in this context as a way of re- establishing a minimal degree of phenomenological and cognitive order that allow the patients to approximate their reality in a better way compared with the way they do during the pre- delusional period. In contrast with the way in which the content of mental states are deployed during delusional moods, patients reporting delusions can distinguish between different agents (a spouse being replaced by an alien, a certain entity inserting thoughts into their mind, the ‘organization’ trying to kill them, etc.) and establish basic predictable causal connections between different aspects of their delusions.
For example, patients suffering from thought insertion establish a causal link between the inserted thought and its external author with a relatively high degree of certainty (Mullins & Spence, 2003). As we have seen, these causal connections are missing during the period preceding the adoption of the delusion and this seems to be at the very root of the feeling of unpredictability that pervades the patients’ experience of the world and themselves. The adoption of a certain delusional misbeliefs implies a certain degree of fixation of this belief in the patient’s mind so the creation of a fictional reality through the fixation of a delusional doxastic hypothesis would impose some minimal degree of order and predictability on the patient’s experiential world. The adoption of a delusional belief might help to re-organize the patients’ fragmented reality around a delusional –but clearer in content and more predictable- mental state. However, it is important to note that the adoption of the delusional beliefs is done against a background of true beliefs. The fixation of the delusion in a subject’s mind allows her to move from a generally
191 rarefied reality to a state where only some pieces of her mind are altered (Conrad, 1958). This allows a subject to bring back true beliefs that help her to act more successfully in the environment. Delusional beliefs are always adopted against a background of true beliefs and this is what makes possible for the subjects to recover their ability to be an agent in the world. In this sense, it is usually claimed that delusions are selective, i.e. a deluded subject does not experience her entire reality as a delusion but only some portions of it (Bleuer, 1950). In fact, delusional beliefs tend to interact with other non-delusional beliefs and mental states of the subject (Payne, 1992; Bortolotti, 2010).
From this point of view, delusions would represent an attempt to re-establish some of different aspects of the unity of consciousness that break down in the stages that precede the adoption of the delusion and, through the reappearance of clear true beliefs in the subject’s mind, the adoption of delusions would allow subjects to act more successfully in their environment160. Consistent with this proposal, Mishara (2010) has pointed out that delusions might arise as a tension-reliving strategy. The author’s claim is not that delusions are motivated by the role they play in avoiding psychologically stimuli that threaten the subject’s self-esteem or self-image; delusions are not ‘psychoanalytic defences’. Rather, the adoption of delusional misbeliefs allows patients to organize their field of awareness to make it more approachable. Delusions emerge not as a way of protecting the self from the negative outcome of affective conflict but rather as a way of organizing a subject’s disunified field of awareness to allow potentially successful (mental and bodily) actions of the subject in his environment161. This idea, just as mine, has little to do with the notion of motivated delusions. As Mishara and Corlett (2009) claims:
Delusions are not primarily a defensive reaction to protect the self, but involve a “reorganization” of the patient’s experience to maintain behavioural interaction with the environment despite the underlying disruption to perceptual binding processes (p. 531).
The pervasive feeling of uncertainty experienced by patients – along with other factors, such as cognitive impairments – drives the adoption of delusional beliefs as an attempt to render the world more psychologically and behaviourally predictable and therefore approachable. The
160 Jaspers (1968) indicates that during the period preceding the adoption of delusions, patients tend to have serious difficulties in verbalizing their experiences. Patients seem unable to put together beliefs, thoughts, perceptions and motives into a more or less consistent narrative. Perhaps this way of structuring speech is just another expression of a deeply fragmented and disunified experiential world. In re-organizing their experience of the world and themselves through the adoption of delusional beliefs patients might regain the ability to verbalize and communicate their experience with the direct consequence of securing a minimally functional degree of interaction with the intersubjective world. 161 It is in this sense that while psychological adaptiveness seems to necessarily involve biological adaptiveness, the opposite is not always the case.
192 adoption of delusional beliefs might allow the reorganization of part of the experience of the world into a more or less unitary gestalt that was disrupted during the period preceding this action. The idea is that in the midst of this phenomenologically disorganized experience of the world, patients search for some ‘fixed point’ to which they can cling, and the delusional belief is the outcome of that search (Mishara & Corlett, 2009). The restitution of the predictability in the patients’ world in conjunction with the background of true beliefs of the patients might allow them to act more effectively in their environments.
McKay and Dennett’s argument for the lack of biological adaptiveness of delusional misbeliefs seems to rely on the idea that doxastic accuracy is a requirement for successful adaptation (see p. 509). They say that only true beliefs can approximate reality accurately and successful adaptation requires approximating reality in such as way. One might agree with the first part of this claim, but one needs not agree with the second. True beliefs do certainly help us to act successfully in the world. For an organism to obtain what it needs, the organism needs to have an accurate representation of the world. For example, if a subject S is in need of nourishment and S has the belief that there is a potential source of nourishment in a certain place, for S to get what she needs (food), this belief has to be true. Otherwise, S would not obtain what she needs and it would fail to adapt to its environment.
Now, imagine if S only has false beliefs (for example, that there is food where there is not). In this case, every action of S in the world would be unsuccessful and S would fail to adapt. So it is true that true beliefs help us to act successfully in the world. However, as Haselton and Nettle (2006, p. 63) rightly point out, ‘[t]he human mind shows good design, although it is design for fitness maximization, not truth preservation’. Mckay and Dennett (2009, p. 209) claims that: ‘although survival is the only hard currency of natural selection, the exchange rate with truth is likely to be fair in most circumstances’. However, adaptation is not about truth, but survival, and sometimes, the human cognitive system might sacrifice doxastic accuracy in favour of biological adaptation, as we have seen in this section. As Stich (1990) famously claims:
[B]elief-formation systems that are maximally accurate (yielding beliefs that most closely approximate external reality) are not necessarily those that maximize the likelihood of survival: natural selection does not care about truth; it cares only about reproductive success (p. 62)
The issue here is a subtle one; McKay and Dennett relate successful adaptation with doxastic accuracy only by comparing deluded and non-deluded patients. They ignore the context
193 in which some psychotic delusions emerge and therefore they miss the role they play in such context. As said earlier, a complete analysis of the adaptive role of delusions must consider the specific environment in which the misbelief is adopted. When considering the affective and perceptual context in which some delusions occur, one can clearly see that adopting a delusion can be sometimes an adaptive doxastic strategy that allows a patient to restore a minimal degree of interaction with the environment by re-establishing its predictability. As Corlett et al. (2010) suggest: ‘affectively charged uncertainty drives delusion formation, through establishment of predictive associations that, whilst maladaptive, represent attempts to render the world more predictable’ (p. 353).
Granted, a subject who only has true beliefs and is not undergoing any pre-delusional condition is more likely to be more successful in adaptation than a subject who has delusional beliefs. Nonetheless, if one compares two subjects experiencing the affective and perceptual alterations commented in earlier sections, the subject who adopts a delusional belief would be more likely to recover a functional degree of interaction with her environment than the one who does not, and therefore, in this context, adopting a delusion would be more adaptive than not adopting it. This point brings us to two final remarks:
(i) As I have stated earlier, having a delusion will never be as adaptive as having true beliefs. Having true beliefs will always be better than having delusional beliefs, for they allow subjects to act more effectively in their environment. Certainly, when compared, true beliefs can help us to adapt to the environment in a way that delusions cannot. However, this does not imply that delusions are not adaptive at all. Given that adaptation is a matter of degrees, delusions can also be characterize as adaptive if they help to restore a degree of functional interaction with the environment under anomalous experiential conditions. For example, blood coagulation serves an adaptive function only if an organism experiences physical external or internal damage. Without this condition, coagulation might become detrimental. Thus, it is adaptive for an organism’s blood to coagulate only if the organism experiences physical damage that requires this type of action. In the case of delusions, it is adaptive for an organism to adopt a delusion only if such organism is under the affective and perceptual abnormal circumstances and such action increases the organism’s chances to functionally engage with the environment. In other words, adopting a delusion is adaptive in virtue of the patient’s need to deal with these pre-delusional conditions. As Bloom (2004) claims:
194 The driving force behind natural selection is survival and reproduction, not truth. All other things being equal, it is better for an animal to believe true things than false things; accurate perception is better than hallucination. But sometimes all other things are not equal (pp. 222– 23)
It is important to note that this is by no means to say that it is always adaptive to adopt delusional misbeliefs. Rather, the idea is that by adopting a delusional misbelief under such rarefied conditions patient are more likely to survive than if they did not adopt the misbeliefs. Truth or doxastic accuracy are negotiable under these conditions if such action allows the patient to maintain a minimal degree of functional interaction with the environment. This takes us to the final remark.
(ii) How can adopting a false belief become biologically adaptive? Perhaps the task of making sense of the biological adaptiveness of beliefs needs some refinement, for there might be more than one way for a belief to be biologically adaptive. In some cases, beliefs might be biologically adaptive exclusively in virtue of their veridicality, as in cases of true beliefs. The biological adaptiveness of true beliefs is not independent of their truth or falsity. They help us to act accurately in our environment only if they are true. However, our analysis also invites a different understanding of biological adaptiveness. It is possible to think that the biological adaptiveness of some other type of beliefs, such as delusional misbeliefs produced under anomalous affective and perceptual conditions, is independent of their truth or falsity, but, at the same time, depends on the interaction between true beliefs and delusional beliefs. Delusional beliefs might be adaptive in virtue of contingent facts, namely, in virtue of the circumstances in which they arise and the way they facilitate the adoption of true. Doxastic accuracy should not be seen as the only measure for evaluating whether certain beliefs are or are not adaptive. What our argument shows is that human cognitive systems might dispense with doxastic accuracy in some cases in order to gain minimal degrees of interaction with the environment. Therefore, delusions can become biologically adaptive depending on experiential circumstances.
5. Concluding Remarks
Resisting a number of dominant assumptions in current neuropsychiatric research on delusions, this paper has argued that some delusional misbeliefs arising in the context of psychosis can be conceptualized as biologically adaptive in virtue of the role they play in reorganizing the patients’ field of awareness and how they would allow the adoption of true beliefs. The guiding idea is that if we are to make sense of the adaptive benefits of beliefs, we
195 need to consider the phenomenological context in which they are adopted. A proper understanding of this context would help to clarify the adaptive role of some delusions in the patients’ life. The context that precedes the adoption of some delusional beliefs in psychosis is characterized by profound affective and perceptual alterations that lead to a confusing and disorganized experience of the outer and inner world of patients. This paper has been confined to a consideration of just those kinds of cases of delusions. In these altered contexts, the adoption of delusional beliefs would help to reorganize the patient’s experiential world, securing a minimal functional degree of psychological and behavioural interaction with the environment. So, even if they are the result of different deficits and they are not doxastically accurate, delusions might contribute to increasing a patient’s chances of survival through the reestablishment of a minimal degree of predictability and order in her subjective world.
Perhaps, this is what Jaspers (1963) has in mind when he claims that delusions might provide a merciful way out from unbearable aspects of the patients’ life. Certainly, Jaspers does not endorse a motivational formulation of delusions; therefore, it is quite likely that he is referring to the way in which some delusions might contribute to the reorganization of the patient’s experiential field from a phenomenological point of view. At this point, it is important to highlight that my proposal seems to apply equally to monothematic and polythematic delusions162. Clinical reports show that patients suffering from the many alterations commented in this article can adopt either monothematic (Payne, 2013) or polythematic delusions (Fuchs, 2005), showing this that the adoption of specific types of delusions under these conditions is not a uniform phenomenon. Now, the exact reasons why patients go on to adopt either monothematic or polythematic delusions in these altered contexts is an issue that remains open 163 . Hypothetically, it might depend on an interaction between phenomenological alterations and other underlying deficits specific to different classes of delusion. The important issue here is that my proposal applies to those monothematic or polythematic delusions that are adopted in the context of the many experiential alterations examined in this article.
Let me finish with a simple reflection on the practical consequences of my analysis for the treatment of delusions. Consider cognitive behavioural therapy (CBT), one of the dominant approaches to the treatment of delusions. CBT focuses on the idea that, by reflecting on and then modifying their patterns of thinking, patients can learn to avoid delusional beliefs. One of the
162 When patients exhibit just a single delusional belief or a small set of delusional beliefs that are all related to a single theme, delusions are monothematic. In contrast, if patients exhibit delusional beliefs about a variety of topics that are unrelated to each other, delusions are polythematic. 163 I thank Prof Max Coltheart for suggesting this point.
196 most important components of CBT is the process of questioning the consistency and plausibility of delusions in order to evaluate and encourage alternative beliefs in patients (Chadwick, Birchwood & Trower, 1996). However, if the adoption of delusional beliefs provides some benefits through the reorganization of the patient’s experience of the world, then, at first, challenging the delusion might not be entirely beneficial under certain circumstances. Psychotherapists might decide not to question a delusion if they think that this process is going to disturb the patient’s experience of reality in a functional way. From a functional point of view, challenging the delusion might not be advisable in some cases. The adoption of delusional beliefs might promote the maintenance of a minimal degree of interaction with the environment. Therefore, approaches such as the CBT might need to develop complementary techniques for the treatments of delusions. For example, such approaches might benefit from the promotion of a better understanding of the patient’s affective and perceptual circumstances preceding their delusional episodes. This might help to (i) explore ways of predicting the emergence of delusional phenomena through the monitoring of strong affective and perceptual changes and, (ii) explore alternative ways of coping with such changes under certain circumstances.
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201 Concluding Remarks
Madness has been among us since our very beginnings, perhaps as the most puzzling trait of what makes us human. Certainly, the understanding of this phenomenon invites an exploration of some the most problematic aspects of our nature as a species. The main motivation for writing this dissertation came from my own junior practice in clinical psychology and represents several years of reflection on the philosophical foundations of my own profession. During my training I observed that a number of common practices in psychiatric diagnosis and treatment were based on dubious conceptions about mental phenomena in particular and the human mind in general. As Emil Kraepelin wrote in 1899, ‘the first principle in the psychiatric treatment of mental patients is frankness and unconditional love of the truth. It is just in this point where laymen and doctors make such serious mistakes’. Gradually, I became aware of the high number of unresolved philosophical issues that were underlying my own practice. Similarly, I witnessed highly implausible approaches to psychosis and its symptoms in the humanities. Some theorists even denied the reality of the experiences reported by patients, positions that imply the denial of the patients’ suffering. As I have argued in this dissertation, it is crucial to recognize the experiential and social context in which psychiatric symptoms are produced. However, reducing psychosis to the mere product of an ideology in a subject’s mind is an idea that can be hardly taken seriously.
Recognizing the importance and necessity of a philosophical examination of psychosis, this dissertation engaged with five of the most fundamental disagreements underlying the occurrence of delusions of thought insertion, one of the most complex and severe symptoms of this psychiatric condition. Assuming that there is a close connection between phenomenological description, empirical evidence and philosophical analysis, this work can be understood as an attempt to elaborate novel integrative ways of thinking about different aspects of psychosis. Although each paper contained in this compilation has its own concluding remarks, here I shall clarify and stress the ideas that tie them all together, offering some reflections on the potential future work that these ideas might motivate.
One of the key aspects of the subjective structure of thought insertion is the external attribution of mental agency that characterizes the patients’ reports. This bizarre phenomenon raises a number of questions concerning the nature of one of the strongest intuitions about our mental life, namely, that we are the authors of our own thoughts. The first paper of this collection
202 firstly clarifies the phenomenology of thoughts insertion in light of the question about mental agency. Although the idea of thoughts being experientially passive can be found in some places in the literature, no explicit formulation of it had been previously offered in the context of the discussion about the architecture of attribution of mental agency. Secondly, the paper develops an alternative view of the architecture of attributions of mental agency that denies the existence of a feeling of mental agency and claims that what figures in the phenomenology of thoughts is a ubiquitous affordance of agentive attributability, i.e. the possibility of a thought to be self or externally attributed in terms of agency.
The analysis offered in this first paper concludes that, while bottom-up views of mental attribution assume a rich but mistaken picture of the phenomenology of thoughts, top-down formulations endorse a correct but incomplete view of it. The dialectical significance of the defended model is that it finds a middle ground between bottom-up and top-down positions, integrating their most plausible elements. Thus, it was shown that the inclusion of the concept of affordances into the discussion helped to get a better grasp of the architecture of attributions of mental agency. Adopting a middle-ground between the two entrenched positions in the current literature, the affordance model of attributions of mental agency is able to gain better dialectic traction than either of the positions alone. Future work based on the ideas defended in this paper might include (i) the clarification and application of the affordance model to other mental pathologies involving disturbances in mental agency and, (ii) a further examination of the way in which emotions, expectations and cultural beliefs penetrate the phenomenology of thoughts within a specific context.
Keeping the affordance model in the conceptual toolbox, the second paper tried to resolve a disagreement within the current debate about the formation of delusions of thought insertion from a doxastic point of view. As observed, some of the current dominant approaches to thought insertion characterize it as an abnormal belief rooted in anomalous experiences of different kinds. Nonetheless, the exact role of these experiential abnormalities in determining exact content of delusional beliefs is an open question. After evaluating the main arguments for and against the two main doxastic alternatives to this issue, the paper concluded that some of the objections to both alternatives could be overcome in more or less plausible ways. After, it was suggested that in order to solve this dispute we should think of single delusional beliefs of thought insertion as having various propositional contents. In this sense, patients would arrive at some of these contents via endorsement and at some of them via explanation; therefore, delusional beliefs of thought insertion are best characterized as hybrid doxastic states. In its final
203 section, the paper explored some potential formulations of this hybrid proposal, maintaining that the endorsement-explanation relationship in the formation of delusions of thought insertion depends on, amongst other things, the phenomenal nature of the thoughts of which patients are aware, the surrounding perceptual conditions and the subject’s own psychological architecture. As we can see, the ideas developed in paper 1 directly inform the picture of thought insertion finally proposed in paper 2. Future work based on the ideas defended in paper 2 might include (i) the formulation of hybrid models of other types of delusions, (ii) the clarification of others top- down and bottom-up elements involved in the formation of delusions of thought insertion, and (iii) the development, defence and empirical testing of a full hybrid model of delusions of thought insertion.
The third paper of this compilation was devoted to the examination of the role that affective deficits have in the process of formation of delusions of thought insertion. It was shown that there are good conceptual and empirical reasons to think that affective impairments play a crucial doxastic role in this process. After examining two different formulations of the aetiology of delusions, the paper evaluated a view that tried to integrate the role of affectivity into the aetiological picture of the delusion. However, such a view was proven to be highly problematic. Taking this into consideration, an alternative view was proposed, claiming that negative affects might not only act as directly influencing the content of conscious thoughts, but the framework of meaning in which thoughts are produced. This view offers a broader understanding of the way in which affects can affect the production and conscious appearance of thoughts and therefore contributes to the understanding of the general process of thought-production. Arguably, future work based on the ideas defended in this paper might include (i) a further understating of the way in which negative affectivity might be implicated in the formation of other cognitive and perceptual delusions, (ii) a further treatment of the way in which affective deficit might complete the aetiological picture offered by two-factor views of delusions and, (iii) the development of specific therapeutic techniques for the treatment of delusions that consider the role of subjects’ affects in the process of production of delusional beliefs (see section 8 of the paper).
Taken altogether, the first three papers of this compilation offer a novel understanding of the aetiology and architecture of delusions of thoughts insertion, considering phenomenological, psychological and empirical conditions. Keeping all these ideas in mind, the fourth paper examined a much larger discussion that overlaps with the debate about the subjective structure of thought insertion. Philosophers endorsing a self-presentational view of consciousness maintain that an experiential sense of mineness intrinsic to all conscious experiences is a necessary
204 condition for a subject to become self-aware. Thus, the type of self-awareness naturally entailed by phenomenal consciousness would necessarily require an experiential sense of mineness to exist. This paper showed that cases of thought insertion - in conjunction with cases of depersonalization and Cotard delusion – undermine this latter idea, and that such an experiential requirement is not really needed to account for the most minimal form of subjectivity entailed by phenomenal consciousness. The purpose of this paper was not to deny that the sense of mineness might play a role in explaining non-psychotic forms of subjectivity. It seems plausible that an experiential sense of mineness might play an important role in making sense of less fundamental forms of human subjectivity, such as a narrative or social self-awareness, that might be also diminished under pathological conditions. The main issue is that, in light of the offered examination, it is not entirely clear what role this might be. Certainty, future work based on the ideas defended in this article will include (i) the clarification of the specific role of an experiential sense of mineness in the task of understanding the different forms of human subjectivity and, (ii) the understanding of the conditions underlying the alterations of the sense of mineness in the context of mental pathologies.
Finally, relying on some of the ideas defended in paper 1 and 3, the last paper of this compilation engaged with a more general discussion regarding the very nature and role that delusions play in human life. This paper claimed that there are good reasons to characterize a certain type of monothematic psychotic delusions (including thought insertion) as biologically adaptive. It was argued that, in trying to make sense of the adaptive benefits of psychotic delusions, such phenomena needs to be understood in the altered perceptual and affective context in which some of them are adopted. Careful examination reveals that during the period preceding the adoption of some delusional beliefs patients gradually lose their behavioural and psychological connection with their environment and this disconnection decreases the subjects’ chances of survival. However, in characterizing delusions, current dominant approaches fail to integrate this context into the aetiological picture of the phenomena, missing the role that the adoption of some delusional beliefs might play in reorganizing the patients’ disunified and overwhelming (inner and outer) experiential world. From this point of view, it was argued that the adoption of delusional beliefs contributes in some cases to the preservation of behavioural and psychological interaction with the environment as an attempt – however pathological – to render the patients’ reality more predictable and approachable. Future work based on the ideas developed in this paper would include: (i) further recollection and examination of empirical and phenomenological evidence on the affective and perceptual alterations that characterize the context in which delusions are adopted, (ii) longitudinal observations of the development of
205 psychotic episodes over time, focusing on the way in which delusions might contribute to the re- structuring of the patients’ general field of (inner and outer) awareness and, (iii) the development of specific therapeutic techniques that consider the potential beneficial role that some delusions might have in the patient’s life (see last section of this paper).
Certainly, madness can be regarded as the mystery of mysteries, its understanding requiring a great deal of interdisciplinary research. In itself, psychosis motivates a number of puzzling questions about the very nature of the human mind, and perhaps about the very foundations of what makes us human. However, if the main ideas sketched in this dissertation are right, it seems plausible that we are on the right track to developing an integrative and more comprehensive understanding of one of the most severe symptoms of psychosis, i.e. delusions of thought insertion. It is my hope to have not only advanced the conceptual understanding of delusions of thought insertion, but also to have outlined some basic ideas for the understanding of more general issues related to psychosis, and for the future development of therapeutic techniques aimed at helping those suffering from this disorder.
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