Persecutory delusions: a false, meaningless pathology? A critique of the use of psychopathological conceptualisations of paranoia in Counselling Psychology practice.
The term 'paranoia', and its synonymous use with 'delusion' and mental 'illness', has become part of everyday discourse, both imbued from and permeating psychiatric diagnostic taxonomies including the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013; Dowbiggin, 2000). Whilst common use implies we hold a firm idea of what paranoia means clinically, conceptualisation has historically created significant confusion and controversy in the psychopathology paradigm (Harper, 1994; Munro, 1999; Mullen & Gillett, 2014). Indeed, modernist diagnostic reification of paranoid thoughts as 'persecutory delusions', construed as false, meaningless beliefs under the rubric of schizophrenia spectrum and psychotic disorders (DSM-V, 2013), has been criticised for positioning human suspiciousness within a discourse of pathology, dysfunction and deficit (Boyle, 2011). Consequential positioning of paranoid delusions as decontextualised, objective phenomenon indicative of individual internal pathology has further created theoretical confusion and fuelled deep-seated philosophical debates regarding the nature of perception, reality and meaning in human distress (Szasz, 1974; Parker et al., 1999; Bentall, 2003).
As counselling psychologists the nosological medical framework conflating psychological distress with 'objective' illness or deficiency is inherently incongruous with the existential-phenomenological philosophy and humanistic value base that underpins our profession (Orlans & Van Scoyoc, 2009), which emphasises the centrality of subjectivity and discourses of client well-being and empowerment (McAteer, 2010). Nonetheless, this medical discourse dominates in the context of mental health today, largely constructing and reinforcing socio-historical, political and economic ideologies which influence our working environments, evidence-based guidelines and ways we formulate and therapeutically engage with human distress (Ivey & Ivey, 1998). Counselling psychology thus appears embedded in a 'logical absurdity' (Williams & Irving, 1996, p 6) wherein our post-modern advocation of dialectical pluralism dictates engagement with these diverse ontological and epistemological tensions in synthesising psychology's 'grand narratives' with retaining commitment to clients' (and therapists') phenomenological understanding and co-constructed meaning in therapeutic practice (Milton, Craven & Coyle, 2010). It is therefore considered our ethical responsibility, as reflective-scientist-practitioners, to critically and inquisitively examine how assumptive frameworks constructing normality/deviance actively inform and create our understanding, formulation and engagement with human distress and diagnostic concepts in practice (BPS, 2014; Larsson, Brooks & Loewenthal, 2012).
This paper therefore critically explores and questions the current psychopathological conceptualisations of paranoid delusions as a false, meaningless phenomenon, and how this understanding can affect therapeutic approach, process and notions of recovery within counselling psychology practice. I will argue the positivistic understanding of delusions is inherently problematic and potentially detrimental to the interactive and dialogically co-constructed therapeutic process and relationship. An alternative existential-phenomenological consideration of delusions as real, meaningful and functional for the human being will be provided, reformulating them as an intentional way of being-in-the-world in response to felt overwhelming anxiety. Conclusions will highlight that existential-phenomenological theorising provides an opportunity to develop a more holistic, non-pathologizing understanding of paranoid delusions, ontologically consonant with counselling psychology's ethos, which can potentiate a more dialectical way of engaging with people in distress beyond diagnosis.
A false, meaningless belief?
The DSM-V (2013) defines persecutory delusions as 'fixed beliefs' (p 87), construed as propositional attitudes or distorted perceptions bound by, and to be analysed under the constraints of falsity, rationality, plausibility and conviction in determining difference from other over-valued ideas. One of many identified delusional phenomena defined based on content, predominant themes in the content of persecutory delusions concern: 'being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed or obstructed in the pursuit of long-term goals' (p 92), classifiable 'bizarre' in nature when 'clearly implausible' or 'not understandable to same-culture peers' (e.g. expressing loss of control over mind/body; p 87). Considered symptomatic of many psychological, neurological and medical disorders (e.g. schizophrenia, delusional disorder, bipolar disorder, dementia, schizotypal personality disorder), persecutory delusions are often associated with high levels of distress, aggression, suspiciousness, ideas of reference and non-compliance, argued to make it one of the more challenging presentations to therapeutically work with (Bentall, 2014; Munro, 1999).
Crucially, the most basic assumption in this diagnostic conceptualisation, often overlooked and unchallenged, is that 'delusion' is considered a fact rather than subjective opinion (Berrios, 1991; Harper, 2004). Embedded in a medical-model of 'abnormality' underpinned by positivism, a form of philosophical naive realism presupposing existence of a knowable and observable singular reality partitioned from a knowable self (Ponterotto, 2005), this pragmatic classification system adheres to nosology in assuming ability to systematically categorize, define and predict 'objective' disorders and symptoms which fall outside the rubric of 'normality' (Parpottas, 2012). Conceptually, the very reification of paranoid delusions does give the impression it is a distinct 'abnormal' entity or recognisable belief system that constitutes an outward sign of internal pathology (Aho, 2008), qualitatively divergent and distinguishable on the basis of systematic investigation of falsity from 'consensus reality' (Boyle, 2011; Mullen & Gillett, 2004). However, most people have experienced feelings of suspiciousness and mistrust in their lifetime, with estimates of prevalence of severe persecutory thoughts amongst the general population argued to be 10-15% (Freeman & Garety, 2004). It is thus questionable how falsity is objectively determined and against what or whose 'consensus reality'. When and how does paranoia become considered a pathology?
In actuality, determining paranoia as pathological is posited by many to lie in the dialogic connection between clients and therapists, wherein subjective judgements of veracity are made by clinicians based on 'common sense' interpretations of felt plausibility and understandability of another's' beliefs without systematic investigation (Heise, 1988, Maher, 1974, Laing, 1960), a proposition supported by observations of psychiatric assessments (McCabe et al., 2002). Essentially, one person's version of reality is seen as more 'delusional' than the others', with the practitioner granted power to define the 'right' reality by virtue of social positioning (Munro, 1999; Laing, 1960). Not only potentially resulting in the misidentification and pathologisation of emotionally significant beliefs (e.g. religious or political convictions) to stigmatizing and detrimental effect for the client (Bentall, 2003; Boyle, 2011), this has significant implications for the inter-relation of phenomenology and psychiatric/psychological knowledge within the therapeutic relationship.
In practice, philosophical realism and monistic reasoning can provide a dangerous illusionary sense of conviction, a belief in holding essentialist knowledge that allows us to 'know' and regulate the 'acceptable limits' of thinking (Harper, 2013). As such, we can become almost like "thought police" (Mullen & Gillett, 2014, p 28), engaged in challenging and attempting to modify or eradicate error, objectionable values, attitudes, ideas and ultimately idiosyncrasity that falls outside alignment with perceived 'consensus realty', itself arguably shaped by social ideologies and normative assumptions (Szasz, 1974). Indeed, the politically-loaded and contentious notion of 'recovery' within the NHS, which leans heavily on a rationalist and over-cognised understanding of distress, advocates absence of 'abnormal' symptomatology as conducive of mental well-being (Pilgrim, 2007; Davidson et al., 2004). This can perpetuate the problematic conceptual divide between objectivity (matters of fact) and subjectivity (individual evaluation) in practice by a) clinicians having to decide what are abnormal/normal thoughts in accordance with current medical frameworks and b) dictating therapeutic process and outcome on this precipice.
In antithesis to the relatively atheoretical attachment of diagnostic labels to 'symptoms', which mostly provide poor causal descriptions and an unconvincing account of aetiology, counselling psychology does go some way to resist such dogma in utilising formulation to developing workable hypotheses about clients' experiences based on psychological theory (Boucher, 2010). However, alongside use of anti-psychotic medication, cognitive-behavioural therapy is advised by the National Institute for Health and Clinical Excellence (2014) as a form of evidence-based practice to reduce 'symptoms' and educate clients more 'correct', 'rational' or normative ways of thinking and/or acting (Chadwick, Birchwood & Trower, 1999; Milton, Craven, & Coyle, 2010). This approach is again generally underpinned by models of psychological development highlighting dysfunctional thinking styles, abnormal reasoning biases, primary attentional deficits and poor probabilistic reasoning as causative and maintaining such cognitive or perceptual distortions (see Freeman & Garety, 2004). In strictly adhering to this manualised didactic therapy we may thus fail to holistically attend to the debilitating experience of delusions in favour of dismissing them as malfunctioning machinery (Burr & Butt, 1999; Boyle, 2011). Consequently we may not only flout the fluidity and dimensional aspect of human suspicion and mistrust (Dowbiggin, 2000), but we are in danger of de-contextualising and denying the importance of the clients' subjective feelings and experiences behind the delusions (Pilgrim, 2000).
I am not saying CBT is not useful and within our remit as counselling psychologists, only the precipice of application needs to be understood; what are we trying to achieve and for whose benefit? If persecutory delusions just represent a different point of view from our own, considering them symptoms to be 'removed' is inherently oppressive and potentially unethical (Williams, 2012). Schlimme (2009) argues indeed within this realist approach persecutory beliefs can become un-falsifiable and client experiences colonized by professional judgements that disallow subjective meaning or difference to be recognised in favour of meeting our own desideratum for finding and treating 'illness' (Harper, 2013), with their use in practice the source of the objectivity they claim (Pilgrim, 2000). It therefore appears a constitutive concept, the legitimacy and clinical utility of which is questionable.
Meaningless or 'un-understandable'?
In taking for granted naive realism, shaped by the core prejudices of natural science from Descartes' dualistic philosophies and his empiricist successors, paranoid delusions are considered outward signs of an internal pathology only; contexts in which they arise are largely regarded as irrelevant and their content considered meaningless (Dowbiggin, 2000; Aho, 2008). Perpetuating the aforementioned focus on whether the belief as a symptom is present, causing distress in and of itself, the subjective meaning or functionality of the belief for person in their existence and the inherent relational dimension of paranoia is neglected and relegated to a subordinate position (Cromby & Harper, 2009). In actuality, content of delusions has been identified reflective of, and often precipitated by, emotionally stressful life experiences (victimization, persecution, trauma, social-inequality; Harper, 2004, 2011), related to negotiating existential dilemmas (Yalom, 1981; Parker et al., 1999; Munro, 1999) and further influenced by cultural, religious and socio-economic factors (Cromby & Harper, 2009). Moreover, delusions may not reflect beliefs per se, but persecutory value judgements, perceptions and moods, with 'delusionality' arising from disturbed experiences rather than beliefs about such experiences themselves (Aho, 2008). Within nosology there thus appears little room for phenomenology, impact of culture and society, or the client's own efforts to make sense of their experiences, ultimately quelling the complexity and uniqueness of the distressed human being to emerge.
In a reflective account of his own psychotic breakdown, Kiser (2004) proposes in fact formulation of his paranoid experiences in terms of cognitive distortions 'gut the experience of its true meaning and deeper significance' (pp 444). In adhering to an abstract and atheoretical framework, where delusions are represented as an 'empty speech act' (Berrios, 1991), we may thus be missing the important issue entirely; the others' sense of reality, of experiencing and thinking something is real for them (Jaspers, 1963; Bentall, 2014). Adopting want for objectivity seemingly ignores the clients' existential-phenomenological experiencing, wherein they truly feel the persecution, smell it and live in the strange, insecure and isolating world they perceive (Van den Berg, 1972). To the client, their world is real for them, and in challenging and attempting to modify 'false' beliefs we may inherently foster the reactions of non-compliance, aggression and hostility often associated with presentation and poor therapeutic outcome (Stanghellini, Bolton & Fulford, 2013). The core issue thus appears that whilst the clients' world is true and meaningful for them, it is not for us, what Jaspers (1963) doctrines as the 'un-understandable' nature of delusions, which can potentiate a sense of isolation and invalidation for the client, and underpins the precipice of 'irrationality' on which diagnosis depends. A crucial difficulty confronting us then as practitioners is precisely this chasm between abstract 'truth' and what is existentially real for the given person, wherein it is questionable whether clients' and their experiences may be viewed as a projection of our own theories (Bentall, 2014).
In order to empathise with these different senses of reality, practitioners thus need to acknowledge the presupposed world as a phenomenological achievement, recognising individual variability and the importance of understanding clients' own world-view (van Deurzen & Arnold-Baker, 2005). This ability to empathically penetrate the clients' prereflexive existence, to make understandable the un-understandable, whilst ontologically consonant with counselling psychology's ethos is, however, dependent on the willingness to establish a phenomenological encounter within which persecutory delusions emerge as meaningful (Dowbiggin, 2000), something not necessarily advocated in current medical frameworks, and often shied away from by practitioners (Maher, 1974).
What if ...?
Within counselling psychology there is an inherent dissatisfaction with the fragmentation and depersonalization of human beings resulting from the rationalistic, deterministic, dualistic and positivistic presuppositions within the medical-model, postulating such a position overlooks what it means to be human in the first place (Cohn, 1997; Aho, 2008). Counselling psychology's roots in philosophical relativism, presupposing the existence of multiple, subjectively constructed and equally valid realities each influenced by an individual's lived-experience and contextual engagement with the world (Orlans & Van Scoyc, 2009), posits human existence, as an intersubjective, dynamic and embodied involvement with the world rather than as disinterested contemplation resulting from observation of reality. From this post-modern stance, in antithesis to the dualistic notion that thinking precedes being, the foundation of the existential-phenomenological attitude to theory and practice is grounded upon the notion 'existence precedes essence' (Sartre, 1956); first I exist and engage with the world, only after do I contemplate about it. As such, it emphasises the importance of paying attention to 'little narratives' regarding how clients' create and re-create themselves and their own worlds (Williams & Irving, 1996) which has significant implications for reformulating and reconceptualising our current understanding of paranoia, suspiciousness and 'delusionality'.
Stemming from the work of Sartre, Heidegger and Kierkegaard, many existential thinkers postulate delusions as a natural, functional and adaptive process by which the psyche unreflectively attempts to obviate from otherwise insoluable conflicts, anxiety and uncertainty that are felt to radically threaten the very core of one's sense of self and the world (one's personal paradigm) (Laing, 1960; Jaspers, 1963). In his phenomenological exploration of the onset and recovery process of psychosis for three individuals, Williams (2012) indeed argues that two particular overwhelming existential dilemmas seem to lie at the crux of this form of distress; (1) achieving a tolerable balance between autonomy/authenticity and connection/belonging; (2) maintaining a secure and stable sense of self when the foundation of one's being is profoundly groundless and interconnected. Such dilemmas are thought to lay at the heart of all human experience, with persecutory delusions thus an intentional process of profoundly distorting one's personal paradigm to attempt to cope with felt intolerable ontological insecurity when faced with the finitude, embeddedness, meaninglessness and inevitable suffering and loss that living entails (Yalom, 1980, Van den Berg, 1972). Not only does this take paranoia as a concept away from the nosological field of psychiatrics, wherein the person deemed 'deluded' may simply be caught in an intense wrestling match with the fundamental existential dilemmas we all struggle with rather than pathologically 'deviant', but we can begin to see how the medicalisation of clients' distress can turn moral issues into illnesses that become personalized, internalized and intractable (Williams, 2012).
Although it is certainly questionable whether delusions are a choice, approaching human distress from this perspective allows us to broaden psychiatry's narrow methodological framework by interpreting the self as a socially embedded, relational and inherently dynamic living person rather than an enclosed causally determined body, thus fostering a space to open up such experiences for exploration and externalisation, ultimately putting distress back into its situational socio-cultural context (Cohn, 1997; Cooper, 2003). Rather than concretizing the others' way of being-in-the-world through imposing realist and objectivist presuppositions, the fundamental principle of retaining a hermeneutic phenomenological attitude of openness and valuing dialogical exploration, clarification and contextualisation of the others' idiosyncratic manner of existence in response to the intrinsic temporal, embodied, affective and intersubjective ontological givens of existence is advocated (i.e. the inevitability of death, isolation, freedom and meaninglessness) (Yalom, 1981; van Deurzen & Arnold-Baker, 2005). Primacy is thus given to the therapeutic relationship rather than theory imposition in not only facilitating a space for containment of, integration of, and transcendence from, unbearable affect, but diminishing the inherent loneliness, disconnection and felt 'un-understandableness' potentiating distress; reconceptualising 'recovery' as in rather than from distress (Pilgrim, 2008). Indeed, Van den Berg (1972) states that within an encounter where the client is perceived as an object, therapeutic treatment may not be beneficial. Thus we may need to step from want for objectivity to empathic intimacy in understanding and working alongside this form of human distress.
Although the DSM-V is argued to be a frame of reference providing a meaningful consensus language for research and clinical utility (Pilgrim, 2000), psychopathological conceptualisations of paranoia as a fragmented symptom of cognitive dysfunction fail to conceive of the unfolding situatedness and embeddedness of the living person in a complex sociohistorical world, and how this can cause or contribute to suffering (Larsson et al., 2012). Moreover, the desire to 'rid' clients' of 'abnormal' beliefs in accordance with realist notions of recovery, inadequately captures how such individuals experience, feel and make sense of their distress (Parpottas, 2012). This could detrimentally impact power differentials within the client-therapist relationship, with privileging essentialist knowledge and own understanding of reality potentially negating ability to hear clients' distress and experience.
Indeed Cromby and Harper (2009) argue we need to rethink modernist approaches to distress and develop a non-diagnostic conceptual framework which sees human suffering as meaningful and socially embedded. I believe counselling psychology can open such a dialogue. In retaining focus on the uniqueness of human experience in theorising that delusions are an understandable and functional reaction to the inherent challenges of existence, we have the potential to recapture the nuances of subjectivity and broaden understanding of distress beyond diagnosis in a non-pathological, de-stigmatising manner. Providing a coherent understanding of the aetiology of distress that encapsulates an explanation for the diversity of paranoid phenomena (Williams, 2012), the existential-phenomenological philosophy underpinning our profession allows for exploration of, and reflection on, hidden meanings that lie behind distress, with the aim to strengthen our clients' ability to withstand adversity and live their lives more deliberately (Yalom, 1981).
Although reformulating theoretical understanding of paranoid delusions within existential-phenomenological dimensions holds the potential to transform individuals into embodied beings rather than interactions of mysterious cognitive entities, in the current climate where dualism and reductionism dominate, conveying and working within this view is challenging (Harper, 2004). However, if we strictly adhere to the medical-model conceptualisation we risk undermining our ability as professionals to embrace, understand and value individual difference, uniqueness and subjectivity, and may actually prevent clients from transcending their diagnosis or empowering them to discover new ways of being.
Rachel Osborne is currently completing her PsychD in Psychotherapeutic and Counselling Psychology at the University of Surrey.
Contact: Rachel L. Osborne, Practitioner Doctorate in Psychotherapeutic and Counselling Psychology, The School of Psychology, University of Surrey, Guildford, Surrey, GU2 7XH.
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