Introduction

The question regarding which status delusional realities have in the commonly shared, intersubjective reality of humans has preoccupied psychiatry since its beginnings.1 It is also a philosophically interesting question, since it addresses the certainty and reliability of conceptualizing reality, the reality of reality, so to speak. Undoubtedly, delusional realities of individual persons differ in relevant respects from the reality that is commonly shared by people in their respective common cultural surroundings. Admittedly, one can have certain private views or beliefs that other persons do not share, are critical of, or reject; yet that does not immediately label these private beliefs as delusional ones. Hence, what is so special about delusional convictions? Is the designation "delusional" meaningful enough in order to adequately assign the therapeutic space to a person who holds these convictions? When searching for an answer to these questions, Jaspers' reflections in his 1913 book Allgemeine Psychopathologie, are interesting even today.

Jaspers was primarily interested in the structural change of knowledge found in delusions. The delusional person's knowledge, that is, one's certainty of being persecuted, exhibits an extraordinarily high degree of conviction (unvergleichliche subjektive Gewißheit) and, moreover, the delusional person is immune to any counterarguments or alternative explanations.2 Consequently, the conviction is also incorrigible. This incorrigibility is the central criterion for delusion in Jaspers' view (GP 96). In agreement with Jaspers, Peter Berner has pointed out that the two criteria of the "extraordinary degree of conviction" and of "rejection of alternative explanations" (incorrigibility) are obligatory for the diagnosis of delusion, but that the content of the delusions, which often seems to be impossible, would constitute merely a secondary criterion.3

In addition to these structural features of delusional convictions, it is also important to consider their duration. While for some persons these convictions may last only a very short time, for example between minutes and hours, for others these convictions may last for a very long time, between months and years. I will restrict myself in this essay to the latter forms of delusional realities and will argue firstly that persistent delusional convictions provide security for affected persons in terms of understanding their own experiences. This ordering function of delusional convictions actually is also present in those who harbor only momentary or even changeable delusional convictions. Taking a phenomenological point of view that is compatible with Jaspers' work regarding delusion, Osborne Wiggins and Michael Schwartz argue that the lack of automatic structuring leads to a vulnerability and openness that makes the emergence of delusional convictions more likely:

With the weakening of its automatic syntheses...mental life loses its normal capacity to structure and stabilize the internal and external stimuli to which it is subjected. Hence the subject becomes too "world-open."4

With regard to persons who harbor long-lasting delusional convictions, it is safe to assume that there must be identifiable reasons that lead to a constant loss of automatic syntheses, for instance, traumatic and aversive experiences or biological or other psychosocial reasons. These considerations can be of further use in therapeutic terms. Secondly, Michael Musalek argues that delusional convictions are reinforced by the behavior of others toward the person in question. He writes:

People who are usually very open and friendly with others may react to the deluded patient with some reservation and resentment because of the patient’s suspicious behaviour. This serves to reinforce the suspicions of the patient. In this manner a vicious circle may be established, amplifying and prolonging paranoid behaviours and ideas.5

This amplification in particular contributes consequently to social exclusion, which is not only considered to be a relevant factor for the emergence of delusional convictions, but also makes it difficult to examine one's own beliefs. It seems all the more important, at least in the therapeutic space, to achieve an encounter and understanding with one another that does not support these two perpetuating factors, namely defusing uncertainty and dismissive psychosocial feedback.

In an attempt to pursue the question regarding an appropriate means of encounter within the therapeutic space, I will apply these considerations here in the context of this essay as well. Hence, I will contrast my introductory general thoughts with the perspective of a person, Birgit Hase, who has held delusional convictions for decades and who is capable of reporting her perspective reflectively. Selected passages of her writing are being included in the next section. This is supplemented by field notes from joint therapy sessions that emerged over the course of several years of therapy. The essay concludes with further conclusions regarding encountering and understanding delusional convictions in a therapeutic space, namely whether delusional convictions should be taken as worldview in order to engage with each other therapeutically.

Learning to Whom to Speak to About it

The following two paragraphs in this section were written jointly by Birgit Hase and me. The name "Birgit Hase" is a pseudonym given to a person who, for many years, hears voices, sees ghosts, and in social stress situations also frequently refers to actions of others or to circumstances of a situation that, from the perspective of others, are not being directed toward her. Thus, she belongs to the group of persons who are formally given a schizophrenia diagnosis and who are identified as having a so-called "chronic pure psychosis" over many years (according to the Bonn longitudinal study of 502 patients this concerns approximately 5% of the persons with schizophrenia diagnosis).6 Birgit Hase was my psychotherapy patient for many years. In the course of time, we had recorded various sessions and used these recordings for writing texts together. We used three transcripts of recorded therapy interviews in order to create this essay.

The first step and turning point on the way of recovery was to learn to whom to speak about these experiences. In this way, Birgit Hase came out of the psychiatric hospital in the late 1980s. In the psychiatric ward, she was given high doses of neuroleptics and suffered motor (extrapyramidal) side effects with dramatic consequences.

The thoughts keep racing, but the body cannot do anything—and the thoughts come: "How am I supposed to do that when I have to go to the toilet?" And then you are asked: "Do you still hear the voices?" And if you say "yes" to them, then you get the drops dumped down your throat. Until the guardian angel told me: "You have to say 'no,' otherwise you'll never get out of here." That's not so easy, not telling the truth.

And so, she decided to speak only silently with the beings from the other world:

We practice speaking with our mouths closed. That was the first thing, pretty much at the beginning, that I had to learn. That's not, that's not...it's not easy. To go from...normal loud talking to inner talking. That's not easy. I had to practice that first.

The breakdown of communication with those who were overwhelmed by the open communication of her psychotic experiences forced her at first to cope with these experiences all by herself. This social camouflage was certainly not a good start, but it got her started.

Since her move to Berlin, now nearly ten years ago, she can talk about this other reality in psychotherapy and in an Open Dialogue oriented polyphonic peer group with the participation of therapists:

In the meantime, I have built up this distance for myself...What has helped me—I have to find myself somewhere. What do they say (in the group)? I know that!...It does me good to hear that and not have their jaw drop. That I can talk about it so easily. I was alone for many, many years—it was terrible, it haunted me even in my dreams.

This reporting and understanding are quite challenging, since it is necessary to develop an attitude in which she can even report about her unusual experiences or her insights that are related to them.

Dual Realities

From a clinical-psychiatric perspective, Birgit Hase reports here on a "double bookkeeping," as it is called in clinical jargon. Or, to say it with Jaspers, of a "double orientation" to reality (AP 101). Birgit Hase had functioned normally then and continues to do so now to the greatest extent possible. Being a single mother of two children and a full-time working registered nurse, she was considerably burdened and showed a high level of social functioning. Yet, her unusual experiences and delusional convictions existed in parallel to this, thereby making them understandable to her. However, these convictions did not match the views of the people around her. So, she kept silent about them.

Jaspers' description of delusional disorientation as being a double orientation to reality captures two aspects of it: first, the aspect that from the subject's perspective there is ultimately a unified whole of his lifeworld; second, the aspect that within this lifeworld a specific doubling has taken place. Thus, although the term aptly names important aspects of it, Birgit Hase and I have decided against using it. Rather, we speak of dual realities or of two realities. From our point of view, the phrase "double orientation to reality" upholds the primacy of one of those two realities. This is understandable and sensible from the point of view of the socially shared reality. And, of course, this applies to some extent to any person with psychosis who, after all, also lives among us non-psychotic individuals. In many everyday situations Birgit Hase, too, has usually to participate in the socially shared reality, although she can adjust to this demand by occasionally withdrawing from the social environment. The latter is a typical, quite health-promoting strategy in acute psychosis.

At the same time, Birgit Hase also reports how she managed to overcome the loneliness created by navigating these dual realities. There is the possibility to talk about these experiences without others judging her as being delusional or crazy and to have them listening eagerly and letting her point of view stand, even if they probably see it quite differently in important respects. Birgit Hase succeeds in doing this in therapeutic settings such as in psychotherapy sessions or when partaking in a self-help group. Reporting her experiences allows her to become more distanced to these experiences, even if they are not thereby annulled or directly questioned. At the same time, her perspective takes on the character of a private view of things, which is unusual, but still communicable. For her, by analogy, these experiences belong to the same coin, but just as a coin depicts two different sides, her experiences appear to belong to two different realities, which of course have some features in common. It is her achievement that she can differentiate these two realities. Hence, the question arises whether Birgit Hase's delusional convictions can ultimately be understood as being a special worldview?

Karl Jaspers' Perspective on
Delusion and Worldview

Jaspers would answer this question regarding a special worldview of delusional persons very clearly in the negative. In his view, there are categorical differences between delusional realities and worldviews. For Burkhart Brückner and Samuel Thoma these differences would apply even for forms of worldviews that are systematically self-contained and remain stable—or "mechanical" or "dead," to use Jaspers' words7— in the face of contradictory experiences, such as ideological worldviews. Brückner and Thoma write:

While the madman suffers from a comprehensive process of social alienation and is at the mercy of the deluded meanings that reveal themselves to him and to which he cannot be held responsible, even though they may offer him a certain degree of freedom, the ideologue consolidates himself as the responsible author of his prejudices.8

From their point of view, this interpretation follows Jaspers' thought regarding the relationship between personality and psychosis, which he already postulated in 1913 where he takes into account the development of personality, temporary phases of behavior, and a process toward psychological distortions.

It is within the concept that the development of a personality is simply comprehensible just from the originally known personality. [AP 255]

In contrast to this, processual changes to one's personality can occur forever at any given time. In a widely received publication from 1913, Jaspers writes:

On the other hand, there are psychoses that have arisen from processes, the content of which shows no comprehensible connection with fate, even if, of course, the contents must somehow have been taken from the earlier life, without their experiential value, their value as fate, being the decisive factor for the entrance into the psychosis content (pure psychosis or relapses).9

Even though Jaspers assumed that what is meant by the clinical picture of schizophrenia can be both reactive and processual, he was primarily remembered for his delineation of the processual incomprehensibility in so-called schizophrenia. Incidentally, in his General Psychopathology that had been fundamentally revised in the 1940s, he formulates this incomprehensibility paradigm once again:

The most profound distinction in psychic life seems to be that between what is meaningful and allows empathy and what in its particular way is ununderstandable, "mad" in the literal sense, schizophrenic psychic life (even though there may be no delusions).10

From a Jaspersian point of view the following is thus clear: Delusion, when taken as a categorial form remains indebted to a brain-organic process, and becomes comprehensible only from this perspective, whereas the content of the delusion becomes comprehensible from within a life-historical perspective.

But can these statements do justice to what Birgit Hase reports about her experiences and how she processes them? After all, the delusional reality is only one side of the coin, while on the other side there is a socially shared reality. Her worldview is built upon her experience of dual realities. Last, but not least: Are Jaspers' categorical distinction helpful for having a supportive encounter and foster understanding when meeting with a delusional person in therapeutic situations?

One Worldview Among Many?

Birgit Hase developed the dual realities all by herself in her efforts to deal with her unusual experiences and in her efforts to handle other people with whom she could not talk about these experiences. In the later conversation about these experiences, it then became possible for her to reframe these dual realities once again. With time, they lost some of their absoluteness, as is evident in the following field note:

I can't prove it. But when I've kicked the bucket, then we'll check it out.

These two sentences make it clear that Birgit Hase offers her listeners to either believe her reports or not to believe them regarding delusional convictions. She is not missionary in this respect, and she demands the same tolerance from the listener. To some extent this does appear to correspond to what Jaspers writes about worldview when he argues that the "ultimate force" of a worldview can "never be attained and never be fully grasped," and that when one speaks "of the incomprehensible in an attempt to speak of it in an understandable manner," one is limited to speak in "paradoxical terms."11 The recognition of this ultimate incomprehensibility signifies freedom. Jaspers writes:

For the free one, everything limited is relative (be it the "rational" of thinking, the "tact" in communication, the rules of behavior in civic life, etc.), it is all there for him, not denied, not rejected (e.g., out of resentment), but just conditioned, not unconditional. Yet for the free one there is the unconditioned. [PW1919 293]

When reflecting upon one's thinking, its validation is a matter of "feeling," that is, taking the "heart as compass" (PW1919 294). These views, that are central for upholding the respective world view, are precisely about not knowing, but only believing the incomprehensible as they give support and meaning to life. Jaspers writes:

The absolute certitude in the subjective existence of faith is at the same time always an incertitude in objective formulations: Connected with faith is always this objective incertitude of that which is unprovable. [PW1919 298]

The conversation regarding the ultimate certitudes, or rather incertitude that can only be grasped by faith, comes to succeed in existential communication. This brings the attention to a crucial aspect that yet seems to play a subordinate role in Jaspers' early reflections on worldviews; namely, the role of the listener when considering the question whether something is to be regarded a worldview or not. Jaspers makes this clear in 1919 with the interlocutor's question regarding the "ability to discuss" or the "inability to discuss" (PW1919 267). Jaspers discusses this explicitly with respect to a delusional person, so that the question arises whether a delusion could also be understood as representing a worldview? The answer provided is negative, since these last delusional certitudes just usually cannot be discussed existentially in terms of this incomprehensible incorrigibility. However, so I argue, they can be explored in such a way that a person remains capable of discussion about these delusional certainties in the case of sufficient processing and a certain distancing from these delusional certitudes, as, for instance, in the present case of the double realities. In the sense of: Although I cannot prove it, yet I nevertheless believe in it.

Of course, it must be acknowledged that one does not discuss the correctness of one's own delusional convictions with a psychiatrist on grounds of being convinced of their veracity. Rather it is an invitation for conversation regarding these convictions that are being voluntarily shared. And it is only in very exceptional cases that one does not tolerate the psychiatrist's doubt regarding the sanity and reason of the reported conviction. As one patient said, "It's absolutely convincing, but I can't believe it." It is precisely not a matter of alternative explanations, but above all else attaining an understanding of what has been experienced and witnessed and the recognition of the feelings associated with it. And indeed, Brückner and Thoma argue that in contemporary delusion theories there is an assumption being made that persons are usually only in part convinced of their delusional beliefs (WWH 226). It is conceivable that one can shape this less-than-one-hundred-percent conviction like a faith can be shaped and subsequently engage in a conversation regarding these beliefs in the sense that they are, indeed, an existential communication, just as Birgit Hase has succeeded in doing it after many years of trying to do so.

In contrast, discussions with ideologically convinced people often seem more difficult than these ones, especially since they are being conducted rarely on to the level of the personal meaning of the respective convictions. They remain, as one might say, merely in the cognitive sphere. This could be a criticism of Jaspers' concept of worldview in general, since he excludes the life-historical development of certain views. As psychiatrists would admit nowadays unapologetically, socio-cultural origin, and thus also traditions, as well as one's own life experiences play a central developmental role.

But if Birgit Hase's delusional convictions make certain experiences in life more bearable and manageable for her—a passive formulation is the correct one here, as one does not choose one's delusional convictions—then the question arises to what extent her delusional convictions could justifiably be understood as existential beliefs. They are literally necessary for her survival. And she takes social responsibility for her convictions, insofar as she does not expect everyone to share them and (having) to behave according to them. After all, for many others it can be difficult to interact at this level. Hence again, the question needs further treatment: can Birgit Hase's delusional beliefs be understood as a worldview?

Seen from my point of view, an affirmative answer is plausible. However, it is only possible provided one leaves a narrow, cognitively charged concept of Jaspersian worldview aside and enriches it with aspects of habituality, of psychosocial imprinting, habit, tradition regarding to patterns of feeling, evaluation, thinking, and behavior.

A possible objection at this point would be that the delusional convictions are after all typically experienced and understood as being deeper insights into reality and, hence, change the view of one's whole reality. This is to be understood in the sense of a delusion idea in which it suddenly and completely convincingly occurs to a psychotic person that yes, it is like this or like that (for example, some government agency is stalking you and it is the reason for all the mess you have been living in during the past few weeks). I advance the thesis that this special quality of delusional convictions is worth considering. Birgit Hase reports of experiences in which the archangel Michael appeared to her and communicated with her. In fact, she sees it that these beliefs allowed her to gain more profound insights into reality. For example, she formulated the conviction that everything is energy, even though everything still appears quite real to her in the sense that these words are commonly comprehended. In an ontological sense, then, the other, delusional reality undercuts the normal and socially shared reality in which she encounters other persons. Thus, also in Birgit Hase's case it needs to be acknowledged that delusional convictions have differed from existential beliefs in certain phases of her life and might differ in the future. Namely, whenever they gain this founding quality and are not believed in the sense of existential beliefs, but are simply known in a non-correctable manner (that is corresponding to a hundred percent being convinced of it). However, this founding quality, at least as Birgit Hase reports it, is softened by the non-judgmental reporting of it to others.

Discussion

The encounters between people who have delusional convictions and persons who have no such convictions are challenging. This applies not only to everyday situations, when people with delusional beliefs cannot put them aside intermittently—unlike Birgit Hase who usually has been able to do so for many years—but this holds especially true for therapeutic spaces. In order to enter a conversation with Birgit Hase regarding her inwardness, it is necessary to provide to her an inviting and unprejudiced space for this to happen. Typically, these conversations are not about her delusional convictions themselves—they often remain in the background—but about other experiences she has gone through, be they psychotic or otherwise. Once this initial trust is established, one can learn from Birgit Hase that she had suffered considerable relational traumatization in her childhood and had made experiences of exclusion. Experiences which, from today's point of view in psychology, are believed to be of crucial significance in the formation of psychotic crises.12 In Birgit Hase's case, these experiences are, at least to a large extent, the disruptive motor that contributes to the fact that the passive syntheses of her pre-reflective mental life always insufficiently and automatically fit the ones made by the fellow-humans in the sense of being a socially communicable reality. She experiences this as a basal insecurity, especially in an intersubjective and bodily context. However, one would be unable to share this experience with her, if one would only focus upon these experiences as being delusional convictions, for example, when relentlessly attempting to convince her of their lack of correctness given one's own point of view. On the contrary, one would rather have to offer to her the same ideological abstinence that she herself offers and that would have to be upheld in the interest of a conversation regarding the differences of the experiences. In order to be able to do this authentically, one as an interlocutor must indeed be convinced that one just cannot act from a position of knowledge in the last consequence. In other words, one is already forced on grounds of therapeutic necessity to evaluate the other's delusional beliefs as a worldview. But this can be achieved only by relativizing one's own view of things. In other words, it is not at all about worldviews, but about habituality, of which worldviews are only a small factor, namely the explicitly narratable aspect of some patterns of thought and evaluation. Maybe this is what can be called existential communication in the context of Jaspers' thought. By following this approach, as a fellow human being or therapist, I prevent to confirm and repeat the other's experiences of exclusion, retraumatize the patient in extreme cases and reinforce the necessity of the patient's delusional convictions.

By drawing on Jaspers, I conclude that understanding schizophrenia as a brain-organic process needs to be abandoned. Even if by presenting this conclusion one rejects a decisive thought of Jaspers concerning delusion and psychoses. Yet his writings remain valuable in other respects, namely as a point of reference and as being a partner in discussion. Further, it remains open to clarification whether in this long interrogation of the connection between delusion and worldview any new insight had been gained regarding the question of the reality of reality. At least one insight had been gained, namely that reality is precisely not a primarily cognitive phenomenon. Rather, reality is interpersonal and embodied.