When people talk about delusions they often refer to false beliefs held by people who suffer from severe mental health conditions. What usually comes to mind are clinical delusions in schizophrenia, like the belief that one is receiving secret messages through the TV or is followed everywhere by the secret service. Thus, when a belief is judged as delusional the interpreter is usually making a negative value judgement expressing disapproval. The implication is that the belief in question is incomprehensible and irrational, neither well-supported by, nor responsive to, available evidence. Delusional beliefs are also believed to compromise normal functioning. As such, they are often labeled as pathological and this can lead to the exclusion and stigmatization of the people who have such beliefs.
Lisa Bortolotti challenges this common understanding of delusions in Why Delusions Matter. Bortolotti argues for a more nuanced understanding of delusions and instead of trying to provide necessary and sufficient conditions for a belief to be called delusional she treats the concept as a family resemblance concept and focuses on how, as interpreters, we attribute delusionality to people every day. In a somewhat controversial move, she does not distinguish between clinical and non-clinical delusions and defends the claim that falsity, ill-groundedness and pathology are not necessary components of delusional beliefs.
Not only does Bortolotti claim that delusions need not necessarily be false but she also argues that it is much more challenging than it is commonly believed to conclusively show that delusions are caused by a dysfunction and are, therefore, pathological beliefs. Though she does not deny that delusions breach some rationality constraints, Bortolotti argues that this also happens in the case of some ordinary beliefs, like belief in homeopathy or belief in conspiracy theories, and for this reason there is continuity between delusions and everyday beliefs. She also argues that not all delusions cause harm but they can emerge to address an existing harm. Following on from her previous work (Bortolotti, 2015, 2020), Bortolotti also sees some delusions as epistemically innocent: delusions can sometimes play a positive role in people’s lives in at least two ways. First, they can provide a meaning to otherwise overwhelming experiences. And second, they can enable the agency of those who have delusions — that is, delusions may enable them to pursue aims that are important to them, or to strengthen personal or social identities. So though delusions may be costly they are also often beneficial, as is the case with certain motivated delusions, for instance. This means that such delusions have meaning and though they may be unfamiliar to the interpreter they need not necessarily be implausible. Though delusions might be difficult to understand, given enough knowledge of a person’s past, or given knowledge of a person’s other beliefs, we can reconstruct the reasons for such beliefs and they can be made sense of. What Bortolotti claims delusional beliefs do have in common though is that they are very difficult for the interpreter to understand, they are held in spite of evidence against them and they form part of the identity of the speaker.
It is, however, based on the lay conceptions of delusions that a basic objection to Psychedelic-Assisted Psychotherapy (PAT) arises. Psychedelic-assisted therapy is the treatment of mental disorders through psychotherapy combined with the controlled administration of certain psychedelic substances. The drugs used in psychedelic-assisted therapy, namely MDMA, LSD, Psilocybin, DMT and ibogaine, do not always cause hallucinations. Nevertheless, some subjects undergoing PAT have reported experiencing transformative mystical experiences that resulted in insights that changed their perspectives about life and its meaning. Such mystical experiences include the sense that one transcends space and time, feelings of unity with an immaterial “ultimate” reality and encountering of the divine, experiences of ego dissolution, oneness and cosmic consciousness. These experiences are also often imbued with what William James (1902) called a “noetic quality”, that is, a sense that such experiences involve genuine understanding of something real and a common insight gleaned from them is that there is more to reality than the empirical world we experience every day.
Such reports have given rise to the so-called Comforting Delusion Objection to PAT, initially found in Michael Pollan’s article on psychedelic therapies in The New Yorker in which he writes:
How are we to judge the veracity of the insights gleaned during a psychedelic journey? It’s one thing to conclude that love is all that matters, but quite another to come away from a therapy convinced that “there is another reality” awaiting us after death, as one volunteer put it, or that there is more to the universe—and to consciousness—than a purely materialist world view would have us believe.Is psychedelic therapy simply foisting a comforting delusion on the sick and dying?
According to the Comforting Delusion Objection psychedelic therapy is morally problematic because it foists on its subjects beliefs that are non-veridical. Since such beliefs are epistemically sub-optimal, the objection goes, PAT causes epistemic harm, or at least includes epistemic risk, and therefore the administration of psychedelics for treatment purposes is morally questionable and needs justification.
In what follows I will develop Bortolotti’s work by connecting it to psychedelic-assisted therapy. My aim is to show that the new understanding of delusions put forward in Why Delusions Matter provides us with the means to reject the Comforting Delusion Objection. One can, of course, respond to this objection by biting the bullet and accepting that not only is PAT epistemically harmful, but it works through inducing comforting delusions and hence we should avoid prescribing psychedelic therapy (Lavazza, 2017). But there have been different attempts to show that the Comforting Delusion Objection fails which have focused on its presuppositions. One such response is that mystical experiences are veridical and give us privileged access to reality so PAT does not involve delusions and there is nothing objectionable to it (Richards, 2015; Smith, 2003). Similarly, another response has been that there is no experimental evidence to suggest that epistemic harm actually takes place during PAT (Greif & Šurkala, 2020). It has also been argued that the epistemic status of PAT doesn’t really matter. Therapy is supposed to help patients, so ultimately, we should judge a form of therapy by its results, and if such experiences help patients and have a positive and lasting impact on people’s lives, the question of their veracity is of secondary importance (Flanagan & Graham, 2017). Contrary to this, Chris Letheby (2016) has argued that the epistemic status of such therapies does matter and though we can properly talk of delusions in this case, the serious epistemic flaws of PAT are counterbalanced by its psychological benefits rendering the delusions in this case epistemically innocent. More recently, Letheby (2021) has argued that, contrary to what is assumed by the Comforting Delusion Objection, inducing false metaphysical beliefs is not the main mechanism through which PAT has its beneficial results but it works by bringing about a change in how a patient sees himself and his life through experiences that are compatible with naturalism.
Taking off from these previously offered arguments and based on Bortolotti’s new understanding of delusional beliefs, I will focus on whether the beliefs sometimes adopted during PAT should be properly called delusional. In Why Delusions Matter, but also in her previous work (2020), Bortolotti has shown that it is important both philosophically and clinically to reassess delusions in order to treat people who live with delusions better. This is also the case for PAT. Studies show that PAT has significant and long-lasting antidepressant, anxiolytic, and anti-addictive effect that take place much faster than other available treatments and that it can address existential distress, something that goes beyond the current limits of therapy (Carhart-Harris et al., 2018; Johnson et al., 2019; Schenberg, 2018). Reassessing delusions in a manner that can address a major objection to such therapy can thus contribute towards the acceptance of PAT as a legitimate form of therapy and, hopefully, allow us to help people more effectively.
1 The Comforting Delusions Objection and naturalism
The Comforting Delusion Objection assumes the falsity of delusional beliefs in accordance with the lay conception of delusions described above. This everyday understanding of delusions is not very different from the definition of delusions in the official classification systems of mental disorders. According to ICD-11 (World Health Organization, 2019), a delusion is
A belief that is demonstrably untrue or not shared by others, usually based on incorrect inference about external reality. The belief is firmly held with conviction and is not, or is only briefly, susceptible to modification by experience or evidence that contradicts it. The belief is not ordinarily accepted by other members or the person’s culture or subculture (i.e., it is not an article of religious faith).
And according to the DSM-IV (American Psychiatric Association, 2000) a delusion is
A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility.
In the DSM-5 (American Psychiatric Association, 2013), however, the definition has changed: delusions are no longer described as false beliefs but as fixed beliefs, not amenable to change given available conflicting evidence.
In introducing the Comforting Delusion Objection, Pollan refers approvingly to a materialist world view, which is a kind of philosophical naturalism, and it is in contrast to this that the beliefs acquired during PAT are judged to be false and, ultimately, delusional. This requires a little explanation. Naturalism has been understood in different ways but generally it can be understood as either or both of the following two claims:
an epistemological/methodological recommendation about which genuine knowledge can only come through empirical/scientific research;
a metaphysical or ontological view of what it is for something to be natural, plus the claim that the natural, so conceived, is all there is.
Following (ii), naturalism is usually (though not invariably) linked to the materialist or physicalist worldviews (Vintiadis, 2013).
Let’s suppose that Pollan is assuming philosophical naturalism in something like this sense: the real is only what natural science says is real. This is, of course, a bold assumption. “All there is is what science says there is” can be understood as a regulative principle of the sciences, but it is not itself a piece of scientific or empirical knowledge. The real is what exists, but to say that this is exhausted by what science (or a privileged part of it) says there is, makes anything not tackled by that science supernatural, a questionable idea to say the least. Moreover, as a metaphysical belief, the belief in naturalism is neither conclusively proven nor universally accepted (Greif & Šurkala, 2020). So, dismissing beliefs as non-veridical and delusional based on a contested and controversial philosophical view is itself problematic — especially when it comes to issues like the ultimate nature of reality, or of the nature of consciousness.
As we have seen, according to Bortolotti implausibility, unshakeability and centrality to identity are jointly sufficient for identifying a belief as delusional (although this being a family resemblance term, all these admit of degrees). So, we can ask: are non-naturalist beliefs of the kind identified by the Comforting Delusions Objection implausible and unshakeable identity beliefs?
2 Implausibility
The first thing to note is that implausibility depends on context; what is considered implausible in one context may not be so in another. Both the ICD and DSM definitions of delusions imply that what is implausible will differ from community to community or culture to culture. As Bortolotti (2023) points out, people with different epistemic commitments or valuing different methodologies will judge the implausibility of beliefs differently. So already the criterion of implausibility is difficult to pin down. In the case of the Comforting Delusion Objection, however, the content of the belief referred to will not necessarily be considered implausible by all, or even most.
It is not straightforwardly false or implausible to interpret an unusual experience such as a psychedelic experience in non-naturalist terms, and even if an interpreter does not agree with such an interpretation, he need not assume that the beliefs came out of nowhere. The idea that there is something more than just the material world described by science will be shared by many people in the world, and such a transcendental belief is, arguably, at the core of religious belief (Crane, 2017). Indeed, psychedelic drugs have been used for centuries in religious and healing practices as means to mystical experiences that lead to insight and spirituality and many people believe that they do so through opening access to a deeper level of reality. Another experience that is often related by people who have undergone psychedelic experiences is that of ego dissolution, the sense of losing one’s self in an experience where the boundaries between one’s self and the world disintegrate (Nour et al., 2016). It might be difficult to imagine what this might feel like, but the idea of the absence of a self will not seem implausible to philosophers that support a non-realist view of the self, many Buddhists or practitioners of certain forms of meditation (Letheby, 2016).
3 Unshakeability
The other characteristic of delusions that Bortolotti introduces is that delusional beliefs are unshakeable. In this sense, what is problematic about them is not so much the content of the belief but how one believes it. Even though people have been known to overcome delusions, and delusions can be sometimes modified to accommodate evidence against them, delusional beliefs are rarely wholly dismissed in the face of counterevidence. So, are beliefs acquired through PAT similarly unshakeable? This does not seem to be case.
First, though subjects may be led to adopt non-naturalist beliefs in order to make sense of powerful experiences, there is no conceptual necessity that takes them from such experiences to non-naturalist beliefs and there are also subjects who do not report the adoption of metaphysical beliefs after PAT (Nayak et al., 2024). Second, even when PAT does result in the altering of metaphysical beliefs, and even if the noetic feeling accompanying such experiences may sometimes make them more difficult to revise, such beliefs need not be unshakeable in the sense that they are held in the face of compelling evidence against them (Timmermann et al., 2021).
PAT is not just about having psychedelic experiences. It is more than just a matter of “set and setting” — that is, of assisting with the participants’ mindset and making sure the physical and social context is supportive for the psychedelic experience. PAT is principally a kind of therapy that uses psychedelic substances as a way of enabling the therapy. The therapeutic framework includes of pre-session preparation and post-session work with the patient. During the integration phase of the therapy, one works on one’s narratives and the experience can be reframed, so what ultimately will be made of the experience and what beliefs one may acquire depend on a number of factors, including one’s other beliefs, one’s character, one’s previous experiences and so on. In addition, people undergoing psychedelic experiences are aware that these experiences are the result of ingesting a psychedelic drug and that plays a role in how these experiences are interpreted. We are not a blank slate on which the psychedelic experience writes. Letheby (2016) mentions the case of a cognitive scientist and philosopher who has had over 130 psychedelic experiences and who, possibly due to his professional training, rather than giving a non-naturalist interpretation to his experiences interprets them in a poetic manner. In fact, Pollan (2018) himself has undergone mystical experiences (according to the Mystical Experience Questionnaire, a self-report measure used to assess the effects of psychedelics) during psychedelic experiences that have not affected his belief in naturalism. This is not to say that non-naturalist beliefs cannot be adopted as a result of psychedelic therapy, it just means that this is not a necessary result of it. If beliefs are adopted they might indeed be held strongly in some cases, but the problem in such cases may not be that one holds on to a belief tenaciously but, rather, that it is unclear what empirical evidence can be offered to overthrow such a metaphysical belief.
4 Identity Beliefs
Lastly, Bortolotti (2023) argues that delusions are personal identity beliefs because they reflect and shape our personal identity. Identity beliefs, like the belief that I am Greek, gay or a democrat, are beliefs that are explicit, in the sense that they are consciously endorsed on the basis of subjects’ experiences and significant views, and thus integrate with other beliefs they have. They are also often the result of our belonging to a community and are stable and emotionally laden — we are often proud of them and loyal to those who share them, and we may harbor negative attitudes towards people who oppose them.
According to Bortolotti, these characteristics are shared by delusional beliefs. We form delusions influenced by our self-conception and they often tell us something about our commitments and identifications. Delusions also tend to dominate our mental life, arousing strong emotional reactions and affecting our actions. They absorb our attention and everything is seen through the lens of the delusion. This can explain why once adopted they are not (easily) dispensable and when they are, the process resembles a conversion. Delusions take the form of personal identity beliefs when they are coupled with a sense of a special access to the truth, of an epistemic expertise of some kind — something we only are able to understand but not others. For example, in the Capgras syndrome we know our loved one better than others so we understand that he has been replaced by someone else even if no one else does. Or, to use one of Bortolotti’s example, if one is in a caring facility for people with dementia but believes one is at home hosting a dinner party, this belief can reflect one’s self-identity as a hospitable person with an active social life.
Many subjects of PAT have reported that the psychedelic experiences they had during PAT were transformative and sometimes these transformations resulted in changes in their personality making them more open to new experiences and ideas, more sociable and so on (MacLean et al., 2011). Transformative experiences are experiences that transform a person either in personal or in epistemic ways (Paul, 2014) and, as such, can affect one’s identity beliefs. However, there are different kinds of transformative experiences. Some, like becoming a parent, may affect one’s identity beliefs. One can, for instance, identify as a mother in ways that spill over into all aspects of one’s life. Others, like a new sensory experience, e.g., tasting marmite for the first time, need not do so. They can be transformative merely in the epistemic sense that you learn something new that you could not have learned otherwise.
One can see the psychedelic experience as resembling a new sensory experience rather than adopting an identity belief in the sense that its fruits are primarily epistemic. You learn something new, or you entertain a new possibility that you would not have before, for example that the self does not exist or that there is more to reality than just the physical world, and this can make you more open and receptive. This, however, does not necessarily go hand in hand with a new ideology or narrative that spills over into the rest of one’s life. A psychedelic experience and the subsequent therapy might change the way one moves through the world, and one might even adopt new beliefs about the nature of reality that can be explicit; but these beliefs do not necessarily seem to fulfill the criteria of identity beliefs. They are not necessarily central to who we are, they need not be unshakable or raise strong emotional reactions and they don’t need to exert pressure, overly preoccupying or concerning the people who hold them.
It is true that one can conceivably become religious after a psychedelic experience and this might become part of one’s identity beliefs but not all psychedelic experiences will lead to the adoption of identity beliefs. When it comes to personality changes that have sometimes been reported after psychedelic experiences, these are sometimes long lasting; but there is also evidence that they diminish over time (MacLean et al., 2011). If such changes reflect adoption of beliefs (which is still an open question), then this could be evidence that the grip of such beliefs is not unshakeable.
It is difficult to do justice to Why Delusions Matter in a short paper. Lisa Bortolotti manages to bring to the fore how delusions are a social phenomenon and that attributions of delusionality affect us all. This is one of the reasons why the fact that she does not distinguish between clinical and non-clinical delusions is actually important, because it allows us to see why delusions matter in how we (should) interact with each other. Bortolotti thus offers a way to understand both the nature and the origins of delusions in a more nuanced and compassionate way that offers more possibility: it allows us to be more understanding of others while also helping eliminate simplistic categorizations that can be polarizing.
In this paper I have argued that this new understanding of delusions can also help dispel the Comforting Delusions Objection to PAT. Past attempts to reject this objection have focused on denying that (we can know whether) the beliefs acquired during psychedelic states are false, on questioning whether they are harmful (or more harmful than beneficial), whether they are the central mechanism through which PAT works and whether their epistemic status is important. I have used elements of these arguments in conjunction to Bortolotti’s new understanding of delusions to reject the Comforting Delusions Objection. The aim was to show that beliefs acquired during psychedelic states in the process of PAT are not delusional since they do not necessarily satisfy the criteria of implausibility, unshakeability and centrality to identity. They are not implausible because implausibility depends on context and the beliefs that may be acquired during PAT, and that the Comforting Delusion Objection focuses on, will not be implausible to many people, including some philosophers. Such beliefs are also not necessarily unshakeable, as empirical evidence shows, even though they may sometimes be difficult to revise. And, though they may be epistemically transformative, since subjects may be led to adopt non-naturalist beliefs about the nature of reality or the self in order to make sense of the powerful experiences they undergo, they are not necessarily identity beliefs that are unshakeable or central to who we are. Ultimately, the hope is that making this clear could help open the way to a form of therapy that, so far at least, seems to be able to help people that cannot be helped otherwise. This is also one more reason why understanding delusions matters.
Acknowledgments
I am indebted to Chiara Caporuscio, our editor, for inviting me to share my thoughts on Lisa’s new book and for all her patience and advice during the process of putting this book symposium together.