Commentary on "Insight, Delusion, and Belief"

There is much value in the approach adopted by Grant Gillett in this exploratory essay on the formation of beliefs within the context of serious mental illness. Gillett's criticism of what he characterizes as a lingering Cartesian account of a "passive picture theory" of mental representations strikes at the very heart of a currently popular approach to the clinical understanding and treatment of the delusions, lack of insight, and poor reality testing often associated with these disorders. Employing the objectivistic and representational epistemology that Gillett indicts, symptom-based assessment and treatment appear to assume the independent reality of a natural world "out there," which is passively taken in by nonafflicted (i.e., "normal") individuals. Impairments in reality testing and belief formation accordingly come to be seen as due to distortions in the reception and/or processing of sensory impressions. Such a view cannot account for significant differences in the perceptual and conceptual worlds of nonafflicted individuals (e.g., cross-cultural differences), nor does it provide much guidance for the practitioner working with a deluded individual other than to argue for the eradication of troublesome symptoms, most likely through pharmacological means. In drawing attention to the domain of tacit, interpersonal skills and experiences through which individuals actively constitute beliefs about themselves, others, and the world at large, Gillett offers an important alternative view rich with implications for clinical theory and practice.

At the core of Gillett's approach is the view that beliefs about oneself and the world develop over time through experiences of an interpersonal and cultural milieu. Without bifurcating this experiential domain from the natural world, this approach argues for the centrality of interpersonal interactions and socialization to normative cultural expectations for rational discourse and judgment in the development of an individual's ways of thinking about and understanding the world. Following Wittgenstein, processes of belief formation are understood as belonging to human "forms of life" that primarily entail actions within a relational context rather than the passive reception of sensory impressions by an isolated individual. Viewing beliefs as forming through dynamic social interactions allows investigators to explore connections between both the genesis and content of delusions and relevant features of a patient's life experiences and family and social environments. As Gillett notes, this approach places the patient as an agent back in the front seat and allows us to consider how affect, meaning, and life experience influence the formation and maintenance of delusional beliefs as one manifestation of a person's active involvement in the process of making sense of his or her experiences.

On a clinical level, such an approach may encourage a different atttitude toward the patient and his or her responsibility in the treatment enterprise. Treatment is no longer something that is done to a relatively passive patient, as in taking penicillin for an infection, but becomes a process of active exploration for both patient and practitioner in tracking the origins and development of the patient's belief system and in considering and reconstructing alternative views of self and world. This approach to the formation and treatment of delusions was originally developed in a restricted fashion within the psychoanalytic tradition (e.g., Bullard 1960), but has more recently reappeared in the empirical, phenomenological, and cognitive-behavioral literature in a series of studies that examine the role of perceptual experiences, life stories and inferential reasoning in the formation and maintenance of delusions (e.g., Davidson 1992, 1993; Garety 1992; Garety, Hemsley, and Wessely 1991; Hemsley and Garety 1986; Jorgensen and Jensen 1994; Maher 1974, 1988; Roberts 1991, 1992; Strauss 1991).

One of the questions currently being debated in these studies is whether delusions are primarily due to the application of normal inferential reasoning processes to anomalous perceptual experiences (such as hallucinations), or whether they are due primarily to biases or distortions in inferential reasoning as applied to normal perceptual experiences. While Gillett seems at times to underemphasize the role of experience in favor of biological distortions of reasoning and judgment in the formation of delusions, his overall approach actually argues for an integration of both of these perspectives. This essay's most important...