The delusions found in clinical settings are extremely puzzling for the epistemologist. So much is this so, indeed, that their peremptory dismissal (until quite recently), in philosophical accounts of belief, certainty, rationality, truth, interpretation, meaning, agency, and intentionality, is cause for surprise. Today, however, that has changed. Much interesting recent material about delusions has come to us –  from philosophers of mind and psychology, from experimental and cognitive psychologists, and from many whose work straddles, and blurs, such disciplinary boundaries.

Lisa Bortolotti’s book on delusions and other irrational beliefs stands out among this material for its clarity, acumen, freshness, and sweep. It is well written and organized, carefully argued, independent and original in its perspective, and fair-minded in its appraisals. It redirects theoretical attention from one, widely accepted paradigm (delusions as irrational beliefs), to another (delusions as disturbances of self knowledge and cognitive authority). And finally, it has the merit of providing lengthy clinical case material sufficient to illustrate the theoretical points made.

Bortolotti takes on a question often asked within recent theorizing about delusions: are delusions belief states?  Answers to that question are of two kinds. Delusions are beliefs; delusions are not beliefs, because they do not share the features on the basis of which we attribute real beliefs (on this account they are either sui generis and something else entirely, or are better seen as akin to some other mental state, such as imaginings). By systematically examining the arguments in support of each of these positions, Bortolotti reaches the conclusion that the former, “doxastic” position is nearer right: delusions are beliefs.

The accessible and elegant structure within which this conclusion is developed makes use of three categories of rationality tied to belief ascription: procedural rationality; epistemic rationality and agential rationality. Each form of rationality as a means to challenge the doxastic conception is dealt with in its own chapter (in Chapters 2,3 and 4, respectively), and each corresponds to a set of traits thought to characterize all or at least many clinical delusions. The argument that delusions are not beliefs derived from procedural rationality says (among other things) that there is insufficient integration between the delusional idea(s) and the subject’s other beliefs. The argument from epistemic rationality toward the same end focuses on grounding – the failure of good evidential support and responsiveness to evidence that is often found in delusions. The argument relying on agential rationality points to another common trait: a mismatch between the deluded person’s actions and other outward manifestations of his or her belief states.

Nested within each of these broad argument types are sub-claims and sub-arguments, whose systematic and persuasive analysis and critique allows Bortolotti to range across the literature of modern epistemology, cognitive and experimental psychology, and psychopathology, and to demonstrate alertness to the complex nuances required when these theoretical assertions are applied to the messy realities of the clinic and lab.

The strategy by which Bortolotti counters arguments against the doxastic position that appeal to the procedural irrationality (understood as inconsistency) involves arguing that ordinary beliefs are also wanting in these ways. And a very similar strategy allows her to challenge the critique of the doxastic account by appeal to both epistemic irrationality (concerning the grounds for forming and maintaining beliefs) and agential irrationality. She emphasizes a pervasive and unwarranted tendency in much argument about these issues: in whichever form it takes, the rationality of non-delusional beliefs is exaggerated and idealized, thus magnifying the contrast between irrational delusions and rational non-delusional beliefs. This is a double standard, and one that Bortolotti rightly insists on exposing. When it comes to the purported epistemic irrationality traditionally attached to delusional thought, she reminds us how prone we all are to bias when we use grounds to form and maintain every class of our beliefs (scientific as well as religious), concluding there can be no “epistemic rationality constraint on belief ascription.” Thus, we understand the “other” in her title: delusions are not distinguished by their status as irrational beliefs.

Having dealt with the doxastic approach to delusions, Bortolotti turns to whether delusions may defy interpretation, rather than rationality. Here, she considers whether delusional subjects lack the ownership and first person authority over these states that normal people do over their beliefs and attitudes, employing analysis largely derived from Richard Moran’s 2001 work on self knowledge.  According to Moran, it is not a privileged form of epistemic access that allows one to acquire first person authority, and hence to know one’s beliefs and attitudes; rather, it is the capacity to endorse them on the basis of what one takes to be one’s best reasons for them. The mounting empirical evidence (from so-called introspective reflection studies), that people can be mistaken about or ignorant of the real sources of their beliefs and attitudes, Bortolotti shows, can be sidestepped by this focus on a deliberative over an interpretive stance. Instead of giving reasons to explain or predict my behavior (adopting an interpretive stance), I exhibit this kind of cognitive authority by determining what the content of that belief is going to be and exercising control over the belief I report on the basis of how things are according to my best judgment and expectation over how they will determine my future behavior. Authorship is not about producing rational attitudes but about acknowledging an attitude as one’s own on the basis of reasons – the attitude may be irrational or unstable, the reasons for endorsing it may not be the reasons it was formed, and I may be mistaken or ignorant about them.

The particular sort of delusion to which Bortolotti applies this analysis is that of thought insertion, and this becomes an extended example to illustrate how the delusional person fails in the authorship of her belief, when that authorship is understood as about one’s relation to the content of a belief, in deliberation or justification. The delusional conviction that “I am thinking someone else’s thoughts” reflects a failure of acknowledgement as one’s own on the basis of reasons. As Bortolotti puts it: “Subjects feel entitled to the beliefs they author and recognize themselves as people who endorse beliefs with those contents. In the case of ‘inserted’ thoughts, there is no entitlement: subjects do not ascribe those thoughts to themselves, nor do they endorse the thought contents with reasons. As a consequence, they don’t see themselves as people who would entertain those thoughts” (page 242). (Not only does thought insertion demonstrate a radical failure of ownership and authorship, moreover, she later concludes, even the belief status of such delusions seems to be thrown into doubt.)

The pages in which Bortolotti develops her account of thought insertion and allied states (such as thought broadcast) are a model of careful, and thorough argument. She lays out earlier accounts of the ownership that seems to characterize thought insertion (work by Gerrans, Gallagher, Campbell, and Hohwy) and persuasively shows that her analysis is a compelling alternative to them.

We are left, however, with a concern: how many other kinds of delusion are illuminated by this analysis? Thought insertion, for instance, is an example of what are known as bizarre delusions, their content is close to incomprehensible, or even self contradictory. Yet many delusions seem to be easier to understand and closer to the epistemic model of irrational beliefs that Bortolotti dismisses. (In her concluding remarks, Bortolotti almost recognizes this, it should be added, but does not draw out its implications.) Delusions of jealousy, for example, seem to be little more than false or dubious beliefs acquired or maintained with inappropriate conviction; they are in no way inexplicable, or difficult to interpret; they are asserted without any apparent lack of authority about their deliberative or justificatory relation to the content of their distorted content. Similarly, the delusions comprising paranoid systems are so carefully supported, and apparently owned and authored on the basis of reasons, that clinical descriptions often note their superior coherence and logic.

Bortolotti rightly points out that authorship and the capacity to manifest the endorsement of delusional ideas in autonomous thought and action are traits that admit of degree. Yet the extreme and bizarre cases of delusion on which she has chosen to focus most of her analysis, while the most interesting, nonetheless bring another worry: they perhaps too forcefully propel her towards issues of autonomy. Even within the clinic, let alone outside it, many delusions appear to leave their subjects’ authority (in the sense she intends), and autonomy in most ordinary senses, unimpaired. There is of course a way to avoid this kind of critique, short of redefining autonomy: we may insist that previous estimates of the class of delusions have been extravagant. If these states actually leave their subjects’ authority and autonomy unimpaired, then they are perhaps better described, along the lines of earlier twentieth century psychiatry, as over-valued or delusional ideas, rather than delusions proper. Bortolotti does not quite assert this restriction but would lose nothing by, and may welcome, it.

The self knowledge absent in delusions of thought insertion has intriguing links to contemporary theories of mind, self, and psychopathology, and some of these are raised in the last sections of the book. For example, disagreements about self narratives and autonomy among theorists such as Dennett and Velleman, and the matter of whether such narratives can be at once fictitious and accurate, are introduced. Bortolotti quotes Velleman — “We invent ourselves…but we really are the characters whom we invent” — in confirmation of her emphasis on the self-fulfilling effect of ownership and authorship, and the force of the deliberative stance.

The point of belief ascription, Bortolotti insists, is interpretation, and she finishes her book with some qualifications on her earlier remarks about when a given mental content achieves belief status. Delusions are beliefs, but only if they meet conditions that would allow interpretation (by ourselves and others) to occur. The minimal conditions of belief ascription include that there must be some inferential relations with other intentional states; some sensitivity to evidence; and the possibility of manifestation in behavior. The link between these conditions and the ownership and authorship of belief states is then summed up: the subject reporting a belief needs to preserve the capacity to express some commitment to the content of that belief, i.e., to own and author it in such a way as to be able to weave it into a personal narrative which will guide future behavior.  If and to the extent that she can do so, then there may be little to distinguish her delusion from the innumerable irrational beliefs to which we are all prone.

For theorists or lay persons, Bortolotti’s book offers a compelling introduction to these strange and intriguing ideas, and it is a worthy addition to the distinguished Oxford University Press series International Perspectives in Philosophy and Psychiatry.

 

© 2010 Jennifer Radden

 

 

 

Jennifer Radden, Philosophy Department, University of Massachusetts Boston