Are People Responsible for Acting on Delusions? by guest blogger Lisa Bortolotti
Consider this case. Bill suffers from auditory hallucinations in which someone is constantly insulting him. He comes to believe that his neighbour is persecuting him in this way. Exasperated, Bill breaks into the neighbour’s flat and assaults him. Is Bill responsible for his action? Matthew Broome, Matteo Mameli and I have discussed a similar case in a recent paper. On the one hand, even if it had been true that the neighbour was insulting Bill, the violence of Bill’s reaction couldn’t be justified, and thus it is not obvious that the psychotic symptoms are to blame for the assault. On the other hand, psychotic symptoms such as hallucinations and delusions don’t come in isolation, and it is possible that if Bill hadn’t suffered from a psychiatric illness, then he wouldn’t have acted as he did.
In the philosophy of David Velleman, autonomy and responsibility are linked to self narratives. We tell stories about ourselves that help us recollect memories about past experiences and that give a sense of direction to our lives. Velleman’s view is that these narratives can also produce changes in behaviour. Suppose that I have an image of myself as an active person but recently I neglect my daily walk and spend the time in front of the TV. So I tell myself: “I have to get out more or I’ll become a couch potato”. I want my behaviour to match my positive self-image so I can become the person I want to be. Our narratives don’t just describe our past but can also issue intimations and shape the future.
According to Phil Gerrans, who has applied the notion of self narratives to the study of delusions, when experiences are accompanied by salience, they become integrated in a self narrative as dominant events. People with delusions tend to ascribe excessive significance to some of these experiences and, as a result, thoughts and behaviours acquire pathological characteristics (e.g. as when Bill is exasperated by the idea of someone insulting him). Gerrans’ account vindicates the apparent success of medication and cognitive behavioural therapy (CBT) in the treatment of delusions. Dopamine antagonists stop the generation of inappropriate salience, and by taking such medication, people become less preoccupied with their abnormal experiences and are more open to external challenges to their pathological beliefs (“How can I hear my neighbour’s voice so clearly through thick walls?”) In CBT people are encouraged to refocus attention on a different set of experiences from those contributing to the delusional belief, and to stop weaving the delusional experiences in their self narratives by constructing scenarios in which such experiences make sense even if the delusional belief were false (“Maybe the voice I’ve heard was not my neighbour’s.”)
As Gerrans explains, self narratives are constructed unreliably in the light of abnormal experiences and delusional beliefs. If we take seriously the idea that self narratives may play an important role in the governance of behaviour, and accept that narratives constructed by people with delusions are unreliable, then it’s not surprising that people with delusions are not very successful at governing themselves.