In my latest posts, I have started to sketch a view about the relationship between autonomy and mental illness. First, I anticipated my thesis, that the capacity for self-governance is not compromised in people with delusions but that success in governing oneself may be difficult to achieve due to failures in rationality and self-knowledge. Second, I have invited you to consider a link between developing self-narratives and exercising autonomy. What happens when self-narratives are inaccurate or incoherent?
In a paper published in 2009, "Mad scientists or unreliable autobiographers? Dopamine Dysregulation and Delusion", Phil Gerrans proposes that people with delusions attribute excessive significance to some of their experiences. When experiences are accompanied by hypersalience, they become integrated in a personal narrative that guides deliberation. If abnormal experiences are attributed excessive significance and weaved into the story as dominant events (as in delusions), thoughts and behaviours acquire pathological characteristics. This approach vindicates the apparent success of some form of medication and of cognitive behavioural therapy. Dopamine antagonists can stop the generation of inappropriate salience and hence the emotional valence of relevant experiences is lessened (see Shitij Kapur's 2003 paper for more details). In cognitive behavioural therapy people with delusions are encouraged to refocus attention on a different set of experiences from the ones that contribute to the delusional narrative, or to stop weaving the delusional experiences in their autobiographies by constructing scenarios in which such experiences would make sense even if the delusional belief were false.
In disorders where memory is seriously impaired (as in dementia, amnesia or dissociative identity disorder), a person can find herself thinking or doing things without being able to provide reasons for them because she has no access to relevant biographical data. The capacity to develop a self-narrative and the capacity to assume moral responsibility for actions seem to be compromised. The case of people with delusions is not typically a case in which self-narratives cannot be constructed at all, but in which they are constructed unreliably, as Gerrans observed. When delusions are integrated in a person’s narrative, they may be paid excessive attention, rationalised and protected from the pressure of external challenges. As a result, the constructed narrative is coherent but largely inaccurate. When delusions are not well-integrated in the narrative, they may be compartmentalised with respect to other relevant experiences and beliefs, leading to the construction of a largely accurate but incoherent narrative or of multiple conflicting narratives. When coherence trumps correspondence, people with delusions may lose touch with reality and with those around them. When correspondence trumps coherence, internal conflicts may undermine intelligibility and agency.
When a delusion becomes integrated in a personal narrative, giving up the delusion can generate lack of self-esteem and confusion about one’s identity. Suppose Jimmy has mistakenly believed for some time that he is an Oscar-winning actor. As a consequence of this delusion, he tells people in the pub about his life in the spotlight, his friends in Hollywood, his excellent salary and his exotic holidays. But in real life Jimmy lives on benefits and has no close friends. What will happen if he is ‘cured of’ his delusion? He will realise that he is not a famous actor, and he will also appreciate that many of the things he believed to be true about himself are in fact false. Jimmy will start seeing his life as unsuccessful and empty. The effects of making one’s self-narrative correspond to reality can be devastating, and many people experience depression when they acquire insight into their delusions.
What's the verdict on self-governance in people with delusions? As I anticipated, I think the capacity for self-governance is preserved, but success in self-governance may be difficult to achieve. But what does it take to be successful at governing oneself? Some suggestions in the next post!