1 Introduction
The prevailing view of delusions as purely harmful and pathological, particularly within the context of experiences labeled psychosis, presents a significant epistemic injustice in the field of mental health (Sanati & Kyratsous, 2015). Individuals with lived experience of these phenomena are often excluded from knowledge-producing spaces due to the stigma of lunacy and irrationality associated with them, hindering both philosophical and empirical advancements in understanding such experiences. In her book, “Why Delusions Matter,” Lisa Bortolotti makes a call to mend polarizing biases and promote better understanding of speakers who adopt beliefs that listeners may consider ‘delusional’ (2023b). She rejects dominant narratives that frame delusional beliefs as solely harmful to the speaker, a biological pathology, or cognitive deficit. Instead, she argues that some delusions are meaningful, beneficial, and adaptive, even if they may also be costly (Bortolotti, 2023b).
Many philosophers and psychologists frame the utility of delusions as meaningful yet suboptimal coping strategies, adaptive misbeliefs to quell uncertainty and prevent crisis, or psychological defenses that preserve a person’s self-construct (Bortolotti, 2023b). Such views can take us a step towards compassion and understanding of the speaker’s lived and embodied context, however they often fail to explore the multiple and diverse functions that delusions may serve beyond coping. Considering delusions as merely or predominantly “imperfect responses to an existing crisis,” (Bortolotti, 2023b, p. 34) can also incidentally re-create paternalistic and dysfunction-centered views. Even if we reject the notion of delusion-as-pathology, it’s still common for some clinicians to believe that delusions are self-deceptive, how fragile brains and minds deal with uncertainty, or a way for the mind to obscure unbearable truths in self-protection, as is common in a psychodynamic view (McKay et al., 2005). Such frameworks tend to focus on the function of delusions as obscuring information or harsh realities, rather than the capacity for delusions to reveal important information.
Bortolotti argues for compassion and respect for the agency of those who hold beliefs that are considered delusional. I aim to take her argument a step further, demonstrating that some delusions are adaptive because they can reveal information about potential sources of harm and pathology. Some delusions, especially ones that arise in the context of trauma and psychosis, can function as the body’s best attempt to alert both experiencers and those around them to sources of harm. In some instances, delusions may function to prevent a crisis or breakdown, whereas in others, they can arise as an adaptive part of the breakdown itself. Some delusions function as necessary alarm bells, and can even be a functional way of escalating a crisis to the point of urgently addressing aspects of the internal or external environment that may be causing harm (Modlin et al., 2023). Utilizing my own experiences with delusions as a complex trauma survivor and someone with lived experience of psychosis, as well as a former mental health worker in first-episode-psychosis programs, I argue that some delusions can provide unique and specialized insights, sometimes with life-saving consequences. I will focus on two examples: delusions as interoceptive information revealing a physical illness, and delusions as subconscious information revealing unprocessed trauma.
2 Uncovering pathology: Delusions as interoceptive information
I paced around my apartment with a sudden feeling of dread, as if something devastating was about to happen, without any external indication of a threat. A growing panic emanated from my ribcage, right below a bloated belly, full from a deli sandwich I had scarfed down. My prediction of danger manifested in three shadowy entities with long spindly fingers trying to poke holes into my gut. I knew they didn’t exist in the way other objects or beings exist and I knew other people could not perceive them. I had the ability to maintain awareness of two realities at once and not confuse the two, however, I could not stop myself from behaving as if there truly were beings meant to harm me. I ran to escape them, and my friends finally found me desperately attempting to cleanse myself of them with water in the shower when the escape had failed. That was the first of many delusions that plagued me for three months. Even when the panic retreated, I was left with an unshakable belief that there were holes in my stomach.
My gut may not have had ‘holes’ in the literal sense, but this delusion was, in some way, both true and life-saving. This was many years before ‘leaky gut’ had become a colloquial term for intestinal permeability, but a friend of mine had recognized my numerous symptoms and pushed me to get tested for celiac disease, an autoimmune disease caused by an allergy to gluten proteins. I tested positive. It may not have been shadowy figures causing my severe and all-encompassing symptoms, but years of going undiagnosed, the disease had compromised my intestinal lining leading to food proteins and bacterial products entering my bloodstream, crossing the blood-brain barrier, and causing brain inflammation among other systemic damage (Lionetti et al., 2015). Celiac-related psychosis is now a well-documented experience, with many researchers reporting on the correlation between celiac disease and schizophrenia (Jeppesen & Benros, 2019; Lionetti et al., 2015; Pollak et al., 2020). Beyond celiac disease, autoimmune diseases in general seem to increase one’s likelihood of having a psychotic episode by about 30 percent (Benros et al., 2011), while a schizophrenia diagnosis can increase the risk of developing an autoimmune disease by 53 percent (Benros et al., 2014).
Although this was not a “true” delusion in the literal sense, since I had no evidence for and was not justified in believing I had ‘holes’ in my stomach, the delusion as a metaphor drew my attention to a very real pathology within my body and pointed me towards uncovering a meaningful deeper truth about the state of my body. Effectively, the delusion saved my life. It served as a signal, alerting me to interoceptive information beneath my awareness, and helping me make sense of confusing internal bodily sensations. Had I considered the delusional belief itself a pathology, merely a cognitive deficit resulting from neurological dysfunction, or just an imperfect way of dealing with a life crisis, I would have failed to understand its deeper epistemic value.
As Bortolotti argues, there is no good reason to consider delusional beliefs pathological (2023b). There very well may be a biological pathology occurring, but the delusion itself need not be the pathology, even if they may arise in the course of a physical illness. Instead of delusions being a ‘defect,’ perhaps “everything is working exactly as it ought” (Garson, 2024b). Delusional beliefs may function as a well-designed signal, pointing us toward a source of dysfunction, pathology, or harm, in this case an undiagnosed autoimmune disease.
There is mounting neuroscientific evidence to support the notion that the body is consistently communicating with the brain through a process called interoception, and that mental experiences, as peculiar as delusions or mundane as everyday emotions, are inseparable from this process (Barrett, 2017; Quigley et al., 2021). The brain keeps track of physiological needs via internal sensations (e.g. our heartbeat or stomach movements) in order to regulate and adapt to changes in the environment, a process known as allostasis (Barrett, 2017; Quigley et al., 2021). However, the brain receives not only bodily information, it also makes predictions based on past experiences and our context to help us prepare for action and predict our body’s energy needs (Barrett, 2017; Barrett & Simmons, 2015). To do that, the brain must also interpret and make meaning of all sensations, including interoceptive ones.
These predictions that the brain makes about our sensations can manifest an instance of emotion, but it can also manifest in other experiences such as delusions (Barrett, 2017). According to neuroscientist Lisa Feldman Barrett, who spearheaded studies on interoceptive networks in the brain:
In a sense, your brain is wired for delusion: through continual prediction, you experience a world of your own creation that is held in check by the sensory world. Once your predictions are correct enough, they not only create your perception and action but also explain the meaning of your sensations. This is your brain’s default mode. (2017, pp. 65–66)
Here she is not referring to delusions in the psychiatric sense, merely in everyday delusions that we may quickly update when we confirm what we predicted was not accurate. Still, she aptly points out that prediction, meaning-making, and interconnected feedback loops between the brain and rest of the body are core default features that help ensure our survival. The brain is always attempting to make sense of our embodied experiences. What happens then when our bodily experiences make little sense?
Proponents of the predictive coding model of psychosis argue that delusions arise as a disruption in the brain’s ability to reconcile incoming sensory information with existing beliefs, due to imprecise prediction error signals (Sterzer et al., 2018). Similarly, proponents of the interoceptive inference theory of psychosis believe delusions result from dysfunctional prediction error signals in regards to interoceptive information (Barbato et al., 2021; Magistretti & Ansermet, 2021; Sterzer et al., 2018; Yao & Thakkar, 2022). Both presume that delusions result from aberrant, pathological processes. However, when we experience extreme, confusing or unusual interoceptive information, it doesn’t naturally follow that the pathology lies in the interoceptive feedback loop, or our inability to update beliefs according to our environment. Moreover, this level of explanation doesn’t tell us much about why the delusion arose or its possible functions. Delusions may be a valid and crucial response to an overall feeling of threat, discomfort, and confusion. Rather than a flaw, delusions may be a feature of allostatic, predictive, and meaning-making processes of the brain (Barrett, 2017). Some delusions could be seen as an attempt to signal that something is wrong, that basic needs aren’t being met, and allostasis is challenged. Delusions may be a necessary and even life-saving response to a crisis which has few external obvious indications.
2.1 Uncovering harm: Delusions as unconscious information
In the throes of psychosis, I found myself overwhelmed by a haunting belief with potentially life-threatening consequences: that the blood in my veins wasn’t my own, and instead it was the blood of my father, who had physically and emotionally abused me from ages three to sixteen. While I did not act on it, the urge to drain myself of his DNA was debilitating and ever-present. This experience confronted me with aspects of my childhood trauma that previously went unacknowledged. I was forced to grapple with the pain of being connected to (biologically and otherwise) someone who could commit such an atrocity. Much like other survivors of childhood sexual abuse, I felt dirty, tainted and unclean.
If someone had asked me prior to psychosis if I had felt uncomfortable being my father’s biological daughter, I would have denied it. Though it didn’t cross my mind consciously, deep inside my body and psyche, it horrified me and had implications for my identity and who I believed myself to be. As is the case for many psychosis survivors, this delusion gave me access to previously inaccessible feelings and beliefs. I won’t argue here for definitions of ‘conscious,’ ‘unconscious,’ or ‘subconscious,’ beliefs – all hotly debated concepts in philosophy, psychology, and neuroscience. While this delusion may not have revealed necessarily ‘new’ information to me, it brought my beliefs to light in a way that finally allowed me to fully experience them and the totality of my trauma in a lived, embodied way. Before this, I experienced the residual traumatic pain as some abstract and disembodied past. Within psychosis, specifically within delusions such as this one, it was as if the story of my body was revealing itself to me.
Fuchs (2011) and other phenomenologists use the term ‘body memory,’ or the “corporeal and intercorporeal unconscious” (2011, p. 69) to highlight ways in which our unconscious experiences are deeply embodied experiences. Fuchs argues that unconscious beliefs, or beliefs we lack some degree of awareness of, are not located ‘vertically’ or “below view” of the psyche, as psychoanalysts often do, but rather ‘horizontally’ in shared lived space within our social relationships and life context (2011). Body memory is most pronounced in trauma survivors, where deeply terrifying experiences can be relieved non-linearly, out of time, and are physiologically distressing (Greenberg, 1998; Modlin et al., 2023). When the body responds to past terror and pain, the mind may not conjure exact memories but rather symbols and metaphors of the same themes (Greenberg, 1998; Modlin et al., 2023). These themes can offer clues and reveal aspects of our identity, beliefs, and emotions that went previously unexamined. Some delusions seem to reveal the body’s narrative, for which linear thought and rational verbal communication are inaccessible (Modlin et al., 2023).
Symbol and metaphor also seem to be core features of many different types of altered states of consciousness, within psychosis as well as intentionally induced states such as psychedelic or meditative ones (Mishara & Schwartz, 2011; Modlin et al., 2023). As new therapies emerge for PTSD and trauma, it's unsurprising that many involve intentionally altering people's consciousness, such as in psychedelic therapies to induce a transformative therapeutic experience (Bird et al., 2021). Some even argue that altered states can be healing precisely because they bypass conscious linear narratives (Mishara & Schwartz, 2011; Modlin et al., 2023; Remy-Fischler, 2021). Rather, they seem to bring about themes that are below conscious awareness but lived in and through the body, “themes not specific to the content, which are naturally unique, but rather to the process; the process of finding out what one can bear to say about their lived experience” (Modlin et al., 2023, p. 560). Once again, this process can be seen as a feature, not a flaw.
It is well known that trauma is one potential root cause of psychosis, and many psychotherapists and clinicians aim to work with delusions, understanding that they are meaningful (Bailey et al., 2018; Loewy et al., 2019). However, all too often, some clinicians see delusions merely as buffering against a reality that is too difficult to confront, or fabricating meaning when life seems to feel empty (Garson, 2024a). Some delusions are not obscuring the harm or painful reality, but rather serve as invitations to parse it out for oneself (Jordan et al., 2019). Of course, not all delusions contain significant themes and metaphors related to past harm or trauma, and treating delusions as some puzzle to be solved may also do more harm than good. However, as Bortolotti points out, “when we seek an explanation for an unsettling event, a satisfactory explanation captures some of the actual causal processes that are responsible for the event” (2023b, p. 5). If we can understand the possibility for some delusions to reveal unconscious themes and metaphors as expressions of legitimate lived experiences of harm, we can learn more about the purpose the delusion may serve. Some delusions, in offering epistemic access to subconscious themes, can also be pointers to sources of harm and violence one may have actually endured or continue to endure.
3 Epistemic justice and the function of delusions
Some delusions seem to tell the story of the body: lived experiences of harm stored in the unconscious ‘body memory’, or interoceptive experiences of physical pathology. Such instances are examples of delusions as functional, rather than dysfunctional, signals alerting the person to crucial information. These examples also explore the function of delusions beyond the ‘imperfect cope’ narrative, which often views delusions as obscuring information too difficult to handle, rather than revealing information and aiding healing. If we want to adequately support people who experience delusional beliefs, especially within psychosis, we must be willing to explore the many possible functions of delusions, and most importantly, allow experiencers of delusions to decide for themselves.
Bortolotti argues, “the delusion seems to emerge to address an existing problem,” (2023b, p. 117) and often this problem may be social, biological, and psychological all at once. That we sometimes can’t express such confusing experiences in logical, socially acceptable ways, doesn’t negate the reality of the harm. In psychiatric settings, it is standard practice for delusional beliefs to not only be pathologized and delegitimized but also left unexplored (Sanati & Kyratsous, 2015; Zangrilli et al., 2014). People are often barred from discussing their beliefs at all due to the clinician’s fear that talking about their delusions may agitate the person further (Zangrilli et al., 2014). The beliefs and experiences of those within such contexts are quickly de-valued and seen as simply a sign of disease, such that the epistemic value of the delusion is cast aside as soon as the diagnosis of mental illness is given. Yet, it is also not uncommon in these settings for delusions to hold some truth value and provide critical clues for how we might better support people.
In a case study presented by Sanati and Kyratsous (2015), a Ghanaian woman who is 2 weeks postpartum and experiencing marital tension and uncertainty about her visa status, presents with acute psychosis. Among hallucinations and agitation, she also reported beliefs about hospital nurses having sexual relationships with her partner, when simultaneously as “the psychiatric team was able to formulate her beliefs as a case of delusional jealousy, they realized that her partner had left her for another woman. This was in fact confirmed by him” (Sanati & Kyratsous, 2015, p. 482). In this example, as with my own case, the delusion may not be ‘true’ or a justified belief, but still has epistemic value as a pointer towards broader truths in the environment and real experiences of harm. If delusions are ways of making meaning, or “a rewarding explanation of personal and social realities that are problematic, then taking away the delusion won’t help us respond to the needs that gave rise to it in the first place” (Bortolotti, 2023a, p. 3). In order to respond to someone’s needs, we must be willing to believe them about their experiences.
If we are to reach Bortolotti’s goal of compassion, we must also aim for epistemic justice and address the systematic exclusion, silencing, and misrepresenting of lived experiencers’ ways of making meaning of their own experiences. Ignoring the potential for important truths behind someone's seemingly illogical belief creates further harm, stigma and discrimination (Sanati & Kyratsous, 2015). It’s important to start from a place of curiosity about the potential truth value of delusions, even if unapparent at first. Many attempts at understanding delusions, even with good intention, can become paternalistic. This can be the case whether we view delusions as a sign of a broken brain or cognitive defect, as a mind obscuring itself from a hidden truth, or as a suboptimal way to cope with uncertainty. These can all be ways that the listener attempts to understand, but with an underlying motive of trying to get the speaker to change, either to see their own self-deception, faulty logic or to realize their underlying ‘disorder’. These explanations are often filled with pity for the speaker, rather than real empathy or respect. To “create an epistemic environment where delusions do not constitute an obstacle to mutual understanding” (Bortolotti, 2023b, p. 147) it’s crucial to understand delusions from a lens of epistemic justice, letting the person be the authority of their meaning-making experience, otherwise compassion remains an empty intention.