When people
experience delusions or hallucinations there is usually some loss of contact
with reality whereby normal processes of thought and perception are disturbed.
As humans, we are all susceptible to experiencing anomalous mental states such
as this. In everyday life, for example, mentally healthy people distortWhen faced
with negative, ambiguous or unsupportive feedback, we
often respond with exaggerated perceptions of control and
unrealistic optimism. In some life situations – in states of delirium,
bereavement, severe lack of sleep and sensory deprivation – it is not uncommon
for hallucinations to occur. The idea that delusions and hallucinations are a
sign of illness or pathology tends to emerge when the belief or experience
occurs outside of such situations and is held to be true in the face of strong
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In a delusion where a person believes
that electronic listening devices are implanted in their brain, for example,
the implausibility of the belief is obvious to everyone else around, but is
held with an unshakeable conviction by that person. Similarly, when
hallucinations occur, such as the hearing of non-existent voices, the person
experiencing the hallucinatory speech may nonetheless believe that others can
hear the voices too (and are lying when they say they cannot), or even
attribute the experience to the possession of a special power such as
telepathy.
The Three
Christs of Ypsilanti
Problems in the self-recognition of
such mind states seem to occur even when they lead to personal distress and severe
disruptions to quality of life. But this difficulty in self-recognition does
not necessarily come from a lack of rational thought. In a 1960s study, The
Three Christs of Ypsilanti, psychologist Milton Rokeach observed
what would happen when three people, each firmly believing they were Jesus,
lived together in very close proximity for several months.
Rokeach wondered how the three men
would react when they realised there was more than one Jesus. Rather than some
dawning of reality, Rokeach observed that each of the men retained their
delusional identities while at the same time rationalising the existence of the
other two. One of the men, for example, thought one was a liar and the other an
angel rather than Jesus himself.
More recently, Startup (1997) studied
a group of psychiatric patients experiencing delusions and
hallucinations. The patients read individual case stories about people
experiencing a range of pathological states of mind. They were asked how likely
it was that the scenarios depicted a mental illness.
reality to enhance their self-esteem and
maintain beliefs about their self-agency.
The patients who
were most fixed in their own delusional beliefs were able to distinguish
between descriptions of delusional and normal beliefs. However, they could not
identify anything erroneous or pathological in their own thought processes. It
would seem therefore that the capacity to identify hallucinations and delusions
in other people might be greater than the ability to see them in oneself.
Self-recognition and help
The appraisal by
people with psychotic disorders that their delusional beliefs and hallucinatory
experiences are non-pathological may have consequences in terms of how likely
they are to ask for or receive help. Put simply, if you do not believe there is
anything wrong with your mental state why should you want to receive medication
or a spell in hospital?
Refusal to accept
treatment is a cause for concern in the care and management of psychotic
disorders where delusions and hallucinations are prominent. In a study of
patients with psychosis, Olli Kampman and colleagues found that self-recognition of one's
psychotic state was an important factor when predicting engagement with
treatment. However, it seems that self-recognition of symptoms is only one of
several factors affecting how (or if) someone engages with recommended treatment.
Following a series
of interviews with patients with psychosis, it was found that the pathway
between the appraisal of delusions and hallucinations and the acceptance of any
need for treatment is one of great complexity. Kevin Morgan and Anthony David identified
five treatment profile types. One of the treatment profile groups
consisted of patients that acknowledged a need for treatment but yet were
non-compliant. For example the patient who said: "I need a skunk, spliff
and a joint to treat me. The doctor's treatment is crap."
In the other
treatment profiles, there were patients who did not believe themselves to be
ill or in need of medical help but were nonetheless engaging with their
prescribed treatment regimens. It was evident that previous experience (or
fear) of medication side-effects played a role in these seemingly contradictory
stances. It also emerged that emotional states had an impact on treatment
behaviour. Interestingly, several patients while appraising their mental states
as "abnormal" did not identify them as pathological, in other words
as a sign of illness.
The identification
of abnormal mental states therefore does not always lead to a belief or
acknowledgement that treatment is a necessary or desirable course of action.
When it comes to treatment, then, awareness is not the same as acceptance.
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