The therapy of delusion in regard to vanitas, sensus communis, and para-position

ABSTRACT

In psychotherapy for individuals with psychotic disorders, the handling of delusional events represents a particular challenge. After presenting a theoretical approach to this topic, this work will discuss pathophysiology and a possible person-centered perspective on this phenomenon. Concrete psychotherapeutic actions will then be extrapolated. Specific characteristics that must be taken into account when interacting with individuals who suffer delusional symptoms will also be presented.

La thérapie du délire du point de vue de vanitas, sensus sommunis et de la position para

Dans la psychothérapie des personnes ayant un désordre psychotique, le traitement des éléments délirants est un défi particulier. Après une présentation théorique de cette thématique, ce travail discutera de la physiopathologie et d’une perspective centrée sur la personne possible de ce phénomène. Des actions psychothérapeutiques concrètes seront alors extrapolées. Les caractéristiques spécifiques qui doivent être prises en compte dans l’interaction avec des individus qui souffrent de symptômes délirants seront également présentées.

Die therapie der wahnvorstellung in bezug auf vanitas, sensus communis und paraposition

In der Psychotherapie mit Menschen mit psychotischen Störungen stellt der Umgang mit wahnhaftem Geschehen eine besondere Herausforderung dar. Nach theoretischer Annäherung an das Thema werden die Pathophysiologie und eine mögliche personzentrierte Sichtweise des Phänomens diskutiert. Konkretes psychotherapeutisches Handeln soll daraus abgeleitet werden. Es werden jene Besonderheiten in der Kontaktaufnahme dargestellt, die in der Psychotherapie mit Menschen, die unter wahnhaften Symptomen leiden, beachtet werden müssen.

La terapia de ilusión con respecto a vanitas, sensus communis y para posición

En psicoterapia para las personas con trastornos psicóticos, el manejo de eventos delirantes representa un desafío particular. Después de presentar una aproximación teórica a este tema, este trabajo hablará sobre Fisiopatología y una posible perspectiva centrada en la persona sobre este fenómeno. Acciones psicoterapéuticas concretas serán entonces extrapolados. También se presentarán las características específicas que deben tomarse en cuenta al interactuar con personas que sufren síntomas delirantes.

A terapia do delÍrio em relaçào à vaidade, ao senso-comum e à para-posiçào

Na psicoterapia de indivíduos com perturbações psicóticas, lidar com realidades delirantes representa um desafio particular. Depois de se apresentar uma abordagem teórica a este tema, discutimos a pato-fisiologia e uma possível perspetiva centrada na pessoa em relação a este fenómeno. São extrapoladas medidas psicoterapêuticas concretas. Também são apresentadas características específicas que devem ser tidas em conta quando se interage com indivíduos que sofrem de sintomas delirantes.

KEYWORDS:

• Delusion
• psychosis. psychosis therapy
• para-position

Delusion

Delusion can manifest itself within the context of a broad range of different psychological disorders: psychoses related to schizophrenia, severe depressive episodes with psychotic symptoms, as isolated delusional disorders, etc.¹ Within the field of psychotherapy, handling the symptoms of delusion represents a particular challenge.

The phenomenon of delusion is even difficult to grasp linguistically. Different languages attempt to describe delusion through figurative expressions. Many languages use the image of delirium (e.g. Délire, delirio, delírio); others, the image of delusion (e.g. Делузија, delüzyon, delusion, deluzija, deluzionális). Delirium literally means the departure from a given track. Delusion is derived from ‘ludere,’ and with the preposition ‘de’ refers to the departure from (correct) play, cheating. Both linguistic images describe the abandoning of something prescribed or generally recognized. The departure from a track or the abandoning of rules of play forces an act of creation: in the finding of one’s own direction or the invention of new rules. Thus, these images describe both the loss and the absence of specific parameters as well as the necessity for one’s own creativity that arises from it.

These aspects of absence, emptiness and creativity are also contained within Germanic languages (e.g. Wahn, waan, vanföreställning). The German word, ‘Wahn', derives from two very similar-sounding words from Old High German: ‘wân’ and ‘wan'. ‘Wân’ means ‘false belief’: this word represents the creative act in finding a new (though incorrect) belief. The other word, ‘wan’ derives from the Latin ‘vanus-a-um'. It means ‘empty’.²

In the history of delusion, it is not surprising that the primary interest has been directed at the creative aspects, which seem far more glamorous than the aspects of loss. In ‘Anthropologie in pragmatischer Hinsicht,’ in which Immanuel Kant (1798) attempts to distinguish between psychological disorders, the author proposes that the origin of madness can be attributed to the ‘falsely inventive power of imagination’ (Kant, 1798/2013; p. 109). Here, Kant emphasizes creativity in the development of psychotic disorders.

But to understand the phenomenon of delusion, the consideration of emptiness is of particular importance. Emptiness – vanitas³ – points the way to the understanding of delusion and its successful treatment.

Sensus communis and sensus privatus

Along with imagination, Immanuel Kant also attempts to address the aspect of emptiness. In ‘Anthropologie in pragmatischer Hinsicht’ he writes: ‘Das einzige allgemeine Merkmal der Verrücktheit ist der Verlust des Gemeinsinnes (sensus cummunis) [sic], und der dagegen eintretende logische Eigensinn (sensus priuatus) [sic]’ (Kant, 1798, p. 151).⁴ ‘The only universal characteristic of madness is the loss of common sense (sensus communis) and its replacement with logical private sense (sensus privatus)’ (Kant, 1798/2013; p. 113). Thus, the productive viewpoint of delusion is demonstrated through the creative development of the emergent logical private sense. The aspect of loss – of emptiness – can, however, also be understood as the abovementioned loss of common sense: as the absence – the emptiness – of sensus communis. Here delusion takes on aspects of emptiness in the respect that one loses common sense while delusional; as common sense is lost, emptiness develops where the sensus communis should be, and sensus privatus can spread there instead. Kant implies in this passage the existence of a sensus communis, of a sense or truth that is shared by society, as something valid independent of the individual. Kant finds the loss of this sensus communis pathological.

Sensus communis and ‘reality testing’

Modern definitions of delusion also seem untenable without consensus on how to evaluate reality. In his 1913 ‘Allgemeine Psychopathologie,’ Karl Jaspers defines the ‘external characteristics’ of delusion as follows: ‘(1) they are held with extraordinary conviction, with an incomparable, subjective certainty; (2) there is an imperviousness to other experiences and to compelling counter-argument; (3) their content is impossible’ (Jaspers, 1913/1997; p. 95f).⁵

Taking into account the ‘content’s impossibility’ as a criterion of delusion, Jaspers seems to imply that the qualification of possible and impossible content in a consensus communis would be clearly recognizable. Subsequent definitions of delusion are based on that of Jaspers. In currently accepted descriptions of delusion, the content of a delusional episode that is considered impossible would also be designated as symptomatic (see Sadock & Sadock, 2007, p. 504). The Glossary of Technical Terms of the DSM-5 also includes such an explication of delusion: ‘A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary…’ (American Psychiatric Association, 2013, p. 819).

This seems problematic, as a test of impossibility is often difficult in practice. In the case of delusional content that is very distant from reality (as in, for example: ‘I feel like I’m being chased by green aliens’) its impossibility is quite obvious. In cases of realistic delusional content, however – such as delusional jealousy – the reality test is more difficult and often impossible. Even outside anamnesis can be of little help. The suspect’s assurances of veracity are still subject to doubt. Of further consideration is that a real occurrence of the delusional fear does not prevent development of delusion, and vice versa. (For example, a sufferer of delusional jealousy may actually have a cheating partner.)

Therefore, it is useful to define criteria that forego any form of reality testing. According to Jaspers’ characteristics of delusion, the first two criteria seem sufficient. The first characteristic Jaspers names ‘subjective certainty’ (Jaspers, 1913/1997; p. 95). The person is convinced with subjective certainty by the circumstance of the delusional content. The reference to Immanuel Kant’s ‘logical private sense’ (sensus privatus) is obvious – especially in conjunction with Jaspers’ third criterion, the ‘content’s impossibility', in which it is not difficult to recognize the ‘loss of common sense’ (sensus communis). Jaspers’ ‘subjective certainty’ is, just like Kant’s ‘sensus privatus,’ something located entirely within the individual.

The second criterion formulated by Jaspers regards the person in contact with the environment. An ‘imperviousness to other experiences and to compelling counter-argument’ is considered a criterion for delusion (Jaspers, 1913/1997; p. 95f). Even if the person has experiences that contradict or refute the delusion, the delusional content is nevertheless maintained. These experiences are redefined, devalued or simply not seen. The same is true for the person regarding comments from his or her fellows, who propose compelling counter-arguments that contradict the delusion. This cannot diminish the delusion. On the contrary, there is a danger that the person trying to refute the delusion is incorporated into the delusional construct with a negative connotation. (As, for example: ‘You just want to confuse me because you’re one of the secret agents that has been threatening me.’)

In assessing the presence of delusion in practice, Jaspers’ first two criteria for delusion are sufficient. A state of delusion must be assumed if a person presents with ‘subjective certainty’ combined with ‘imperviousness to other experiences and to compelling counter-argument.’ Those experienced in psychiatry know that applying the reality test to the ‘content’s impossibility,’ especially as regards realistic content, is neither possible nor expedient. A comparison of the delusional content with the sensus communis is not necessary. In acute psychiatric situations which demand pragmatic action, the question as to the fundamental existence of a universal common sense remains unanswered, and initially seems neither helpful nor beneficial with respect to the diagnosis of the presence of delusion.

Case vignette

An example should further illustrate the description of delusion: let us consider a single man⁶ living completely withdrawn from society. He avoids contact with his neighbors, as he is absolutely convinced that they wish him harm. He repeatedly hears music and TV noises from the neighboring apartment and is convinced with subjective certainty that the neighbors are using these background noises to cover activities meant to harm him – for example, the installation of listening and surveillance devices – because they work for a secret agency that intends to spy on him. Other obvious possible explanations for why music and other noises can be heard coming from the neighbors’ apartment are not accepted by the lonely man. He remains uncorrectable in his conviction and tends to respond to those who try to dissuade him from his delusional thoughts by incorporating them into the events of his delusion as his enemy’s allies, thereby seeing them as hostile as well. Psychopathologically speaking, the delusion can be categorized as persecutory delusion. The man feels negatively impaired by his neighbors. Pathophysiologically, one would suspect this man to be suffering changes in the regulatory process of his thalamic filter.

Pathophysiology of psychosis

In order to understand the pathophysiology of delusion, one must pay particular attention to the prefrontal cortex. According to biological models, this is where processes of value judgment and understanding take place.⁷ Information that is perceived by different sensory perceptions must be evaluated in the prefrontal cortex and meaningfully considered. Every moment, countless sensory perceptions are perceived. Not all of these perceptions, however, are of equal significance in any given situation. While standing on a street corner and conversing with someone, for instance, the brain is largely successful at filtering out the noise of the street in order to concentrate on the other speaker. The acoustic, visual, and olfactory stimuli from the traffic are only marginally or unconsciously perceived. This information must be filtered in order to not assail the prefrontal cortex in an unfiltered, overly large mass. There, primarily the information relevant to the present situation should be perceived.

Correspondent to current theories, the function of filtering this flood of information is taken over by the thalamus. Information from glutamate neurons from various areas of the brain with different impressions are reduced by the thalamic filter and only partially reaches the prefrontal cortex. The functioning of the thalamic filter is regulated by the nucleus accumbens, from which the (inhibiting) gamma aminobutyric acid (GABA) neurons migrate into the thalamus and form the thalamic filter there. Glutamate neurons from the prefrontal cortex serve as an activating agent in the nucleus accumbens for the inhibiting GABAergic neurons of the thalamic filter. This is a feedback loop to regulate the activity of the thalamic filter.

In another feedback mechanism, glutamate neurons in the prefrontal cortex activate GABAergic interneurons, which activate inhibiting dopamine neurons toward the nucleus accumbens through glutamate neurons in the ventral tegmental area.

Pathophysiologically, delusion could then be explained as a hypofunction of glutamate neurons of the prefrontal cortex toward the nucleus accumbens and a thereby diminished activity of the GABAergic neurons that form the thalamic filter. This second feedback loop is also involved in the development of delusion. Through hypofunction of the glutamate neurons in the prefrontal cortex, a hypofunction of the GABAergic neurons can occur, whereby a hyperactivity of the glutamate neurons toward the ventral tegmental area leads to a dopamine activation toward the nucleus accumbens. The result, in turn, is a hypoactivation of the GABAergic neurons that form the thalamic filter.

As a result, a reduction in function of the thalamic filter occurs, whereby there is an increased influx (of sensory impressions) via the glutamate neurons on the prefrontal cortex. The prefrontal cortex is then confronted with a mass of information, which though probably meaningless in the present situation, can seem meaningful. Pathopsychologically, the development of delusion may be understood as a disruption in the regulation of the thalamic filter.

Evaluation of the biological model

The biological view of the phenomenon of delusion has its limitations. It lends us no indication of the possible causes of delusion. Feedback processes are described that lead to defective regulation of the thalamic filter. The answer to why these particular feedback loops arise cannot be derived from the biological model. The biological model does not seem to indicate a lack of information conveyed via the glutamate neurons to the thalamus and on into the prefrontal cortex. It should, however, be noted, that according to this view, all of the incoming information is considered to be of equal importance and meaning – whether the information constitutes a relational experience or the complex pattern on a knotted rug. The model could suggest that the meaning of an experience is determined exclusively in the prefrontal cortex. Bits of information that arrive via the glutamate neurons and which are primarily of comparable value are given significance in the prefrontal cortex. One might say that interpretation of meaning happens only from the subjectivity of the cortex. It almost seems as though there is no meaning beyond subjective perception. According to this view, everything would be only sensus privatus. Significance would be given exclusively in and by the prefrontal cortex.

For as unhelpful as the question may be as to the existence of a sensus communis when assessing psychopathological symptoms in the diagnostic process, it arises all the more in light of a biological model that regards every external experience entering the prefrontal cortex as equally important until it is evaluated by the cortex. A sensus communis would be in this case hardly conceivable. The person centered approach must counter this view, however, with the existence of meaning beyond the subjective interpretation of meaning. Assuming only the evaluation that occurs in the prefrontal cortex is relevant, it would be irrelevant whether the relationship of the therapist is actually empathetic, real, appreciative, etc. How the individual evaluates this would be of sole relevance; that is to say, whether establishing contact is perceived as empathetic, real, appreciative. But experience shows us that a good (therapeutic) relationship cannot succeed if it does not really and truly fulfill the necessary and sufficient conditions (see: Rogers, 1959, p. 213). We must assume that in a beneficial relationship there is also something meaningful outside of the evaluation in the prefrontal cortex of our counterpart. Real relationships would be impossible on the basis of exclusive, singular, and subjective evaluation. From the perspective of the person centered approach, the significance of real relationship must be postulated: a relationship that is not only the sensus privatus of a person’s fantasy, but goes beyond this to extend between people as sensus communis.

Under the assumption that inter-personal meaning exists, the neurobiological view is to be interpreted differently. It can be assumed that not every experience conveyed via the glutamate neurons through the thalamic filter into the prefrontal cortex is to be considered equally important under subjective evaluation. Should a meaning between people exist, the perception of this important relational experience will be viewed differently than other experiences (for example, the complex pattern in the rug) even before its evaluation by the prefrontal cortex. The information of the relational experience is indeed transported via the glutamate neurons; it differs, however, in physiological terms, from other information in a way as yet unexplained by neuroscientists.

Relational experience as a separate quality

If we were to imagine a thought experiment in which there is a qualitative difference of information in the glutamate neurons toward the thalamus and further toward the cortex, this would open a new perspective on the phenomenon of delusion. One part of the information should be considered important relational experience. The above-mentioned case study has been included for clarity. The aforementioned lonely man doubtless has a current deficit of valuable relational experiences. Although the total amount of information that arrives in the cortex via the thalamus seems undiminished, a deficit of relational information occurs – an emptiness, or vanitas.⁸ Taking this into consideration, it is understandable that feedback mechanisms are activated that make the thalamic filter more permeable. The purpose of these mechanisms would be to avoid valuable relational experience being filtered away in the thalamus. More of the necessary relational experience should reach the cortex. In this sense, the activation of feedback mechanisms toward the nucleus accumbens should no longer be seen as pure pathology, but rather as a physiological expression of a principally healthy brain process that is trying to compensate for a deficit, or vanitas.

Consequently, in the search for underlying problems, focus must be shifted away from brain biology and to the primary deficit of valuable relational experience. In our case study, the brain’s mode of reacting by activating the feedback loop is understandable. The deficit of externally perceived relational experiences cannot, however, be thereby offset. The increasingly incoming (due to reduced thalamic activity in the prefrontal cortex) information is not relationally relevant; it seems, however – as it is expected as such – to be valued as relational information. Suddenly, the non-relationally related volume of the neighbor’s television takes on a relational connotation. Delusion unfolds.

The pathophysiological mechanisms that lead to the experience of delusion apparently serve to fill a deficit in the prefrontal cortex. Delusion seems, in this sense, a process that tries to use every indication of relational experience and seeks to avoid the possibility of relational information being lost in the thalamic filter. Eventually non-relationally relevant information is redefined as relationally important. But even this seems useful for the organism. The lonely person is thereby successful in fending off the full extent of his or her loneliness and in living in an awareness of having meaning for others – even if only in a negative, hostile way. But even this is better than the perception of brutal reality; namely, that the person is completely alone and even those supposed to be evil are in no way interested in him or her.

The importance for the organism to have mechanisms at its disposal which fend off the experience of loneliness becomes comprehensible when one considers the risk factors for suicide. Loneliness and social isolation are regarded by many studies as the primary risk factors for suicidal behavior (e.g. Wiktorsson, Runeson, Skoog, Ostling, & Waern, 2010). It was observed that the ‘prevalence of suicide ideation and parasuicide increased with the degree of loneliness’ (Stravynski & Boyer, 2001).

It seems to be of vital importance to the organism to be able to ward off a realization of the full scope of its loneliness. Even Carl Rogers takes into account the tendency of the organism to self-preservation when he describes the actualizing tendency: ‘This is the inherent tendency of the organism to develop all its capacities in ways which serve to maintain or enhance the organism’ (Rogers, 1959, p. 196). Delusion seems to be an option that serves the preservation of the organism. Delusion is, in this sense, a useful, creative defense mechanism.

Delusion is not the illness. The disorder is a deficit of positive relational experience. Delusion is not the problem, but an attempt to solve it. In the interest of simple illustration, the case study chose an obviously lonely person. But not only obvious loneliness must be recognized as a deficit of positive relational experience.

Even seemingly well-integrated people can exhibit a deficit of real, genuine, good relational experience. Carl Rogers writes about the case report of Ellen West by Ludwig Binswanger: ‘When there is no relationship in which we are able to communicate both aspects of our divided self – our conscious façade and our deeper level of experiencing – then we feel the loneliness of not being in real touch with any other human being’ (Rogers, 1961b, p. 94).

Ellen West herself formulates in a diary entry:

I am quite isolated. I sit in a glass ball. I see people through a glass wall, their voices come to me muffled. I have an unutterable longing to get to them. I scream, but they do not hear me. I stretch out my arms toward them; but my hands merely beat against the wall of my glass ball (Binswanger, 1958, p. 256).

Ellen West realizes the deficit. The case study leads to suicide (see: Binswanger, 1957).

This demonstrates vanitas in the sense of empty appearance. Delusion can be regarded as a creative effort of the psyche to keep from fully realizing the deficit of real positive relational experience.

Psychopharmacotherapy

These considerations can be helpful in the treatment of delusion. We will next consider medicinal therapy. Eugene Bleuler, a significant figure in the history of psychiatry (he coined, the term ‘schizophrenia’; see Bleuler, 1911) was grim in his view of the prognosis for delusion. ‘There is surely no cure for paranoia’ (Bleuler, 1934, p. 526), and ‘Nothing can be done for the disease. One has to make the best of it. Some of the patients are best left to themselves’ (Bleuler, 1934, p. 533). This quote comes from a time prior to the introduction of modern antipsychotics in psychiatry. But even with good pharmacological treatment, therapy is often difficult for a delusion that unfolds over a longer period of time. Occasionally, symptoms prove themselves resistant to therapy.

Currently available antipsychotics primarily work by interfering with the feedback loop via the ventral tegmental area by inhibiting dopamine receptors. This should prevent a reduction of activation of the GABAergic neurons from the nucleus accumbens, which move into the thalamus and form the thalamic filter (see: Stahl, 2013). But this medicinal approach only affects the dopaminergically conveyed feedback path; not the path conveyed from the prefrontal cortex directly to the nucleus accumbens via glutamate neurons. Only one feedback loop is psychopharmacologically affected. This could explain many resistances to pharmacological therapy.

According to the thesis formulated above – that the development of delusion is principally a physiological mechanism in reaction to a deficit of real relational experience – it should be noted that a purely medicinal therapy would not treat the cause of the disorder; rather, it would only suppress a reaction to it, one which possibly represents a meaningful coping strategy for the organism. As useful and helpful, and sometimes effective, as antipsychotic psychopharmacological treatments are, it must be urgently concluded based on the considerations above that they are always to be combined with psychotherapeutic treatment. The deficiency or emptiness of positive relational experience should be redressed through a good psychotherapeutic relationship; otherwise, by taking medication, the person’s coping strategy would be unilaterally taken from them without offering them another option – one that is more relationally healing. Psychotherapy has a high significance in the treatment of delusion.

Psychotherapy of psychoses

In order to illuminate the psychotherapeutic characteristics of relationship building with people with delusion, it should be remembered that the criteria for the presence of symptoms are defined by Karl Jaspers’ ‘subjective certainty’ and ‘imperviousness to other experiences and to compelling counter-argument.’ It would, therefore, hardly be expedient to wish to apply oneself to the disproving of delusion. It seems much more useful to pay attention not to symptom-oriented psychotherapy, but to person-oriented positive relationship building. Especially person centered psychotherapy, with its concepts of successful relationship building, can make a meaningful contribution to treatment.

A particular challenge for the therapist is the interaction with delusional content, especially when it appears hardly comprehensible. Contradiction seems useless, as one would founder on the imperviousness of the delusional system. Moreover, any contradiction or attempt to disprove would carry the danger of being perceived negatively and integrated into the delusional construct as an enemy. Further psychotherapy would be difficult. But conduct consensual to the delusional content would also prove inexpedient. To consent to the delusional content would further strengthen it and, in fact, carry the danger of losing one’s own authenticity. The goal of an honest, real, positive relational experience would be aborted by an inauthentic, incongruent relational construct.

The therapist finds himself in the dilemma of not being able to confront the issues of the client’s delusion either affirmatively or negatively. It seems to be most helpful and most authentic when the therapist can successfully resist the temptation to evaluate the delusional content in this or that way, but rather to position himself as an autonomous person with his own views, completely independent from the delusional content of another person. From this completely authentic independence, a respectful encounter between two autonomous people can successfully develop, without reciprocal appropriation into certain (delusional) issues and content.

Para-position

For clarification of this important communication standpoint in delusion therapy, the position of the therapist is designated as para-position (παρά in the sense of with, beside). The therapist positions himself in the developing relationship with the client in emotional proximity with him: though clearly beside him, clearly differentiated from him. Carl Rogers pointedly describes a part of the therapeutic process: ‘The therapist attempts “to get inside the skin” of his client, immersing himself in the world of complex meanings that are being expressed’ (Rogers, 1975, p. 1833). As vivid and helpful as this image is, the therapeutic attitude it describes presupposes that both the therapist and client are aware that the therapist is assuming an ‘as if’ attitude. One must assume that with delusional experience, the difference between ‘as if’ and reality is not always clear.

Over the years, Carl Rogers seems to have shifted to a more Buberian viewpoint (see: Shlien, 2001). In one of his very last papers Rogers writes:

I participate in a miracle. At such moments I feel an almost ectoplasmic bond between the client and myself. It is truly an “I-Thou” relationship. At such important moments of change in therapy, the question of equality or inequality is totally irrelevant. The important thing is that two unique persons are in tune with each other in an astonishing moment of growth and change (Rogers, 1987, p. 39).

But with delusional experience that involves the risk that boundaries get blurred. Rogers himself reports on his work with a client with whom perception got ill-defined: ‘…I got to the point where I could not separate my “self” from hers. I literally lost the boundaries of myself’ (Kirschenbaum, 1979, p. 191f). First, the person entering the relationship must be perceived as an independent, autonomous person. Expressed according to the image ‘to get inside the skin’ depicted by Carl Rogers, to convey first to the delusional person: ‘You’re in your skin. I’m in my skin (and feel good in it).’ From this attitude, para-position succeeds, within the process of relationship building, in communicating explicit respect of the other person’s reality without agreeing to or disagreeing with it.

The explicit declaration of the therapist’s view of reality is of particular importance, because people who are entangled in delusional thought tend to attribute less importance to perceptions outside of their delusional construct. To reach the person with delusional disorder with autonomous statements and real attention, the therapist must express his viewpoint very clearly and in a way that cannot be misunderstood. In this way, this important information can reach the other person.

It is not enough for the therapist to communicate, since the communication must be received, as pointed out in condition 6, to be effective. It is not essential that the therapist intends such communication, since often it is by some casual remark, or involuntary facial expression, that the communication is actually achieved (Rogers, 1959, p. 213).

Rogers formulates the 6th condition as follows: ‘that the communication to the client of the therapist’s empathic understanding and unconditional positive regard is, at least to a minimal degree, achieved’ (ibid.).

The position of the therapist is thereby characterized by corresponding very authentically and clearly to his own viewpoints, which he also freely communicates. The tendency of delusion to allow subjective certainties to develop through suppositions and distrust can be prevented through open declaration of one’s own views in respectful, non-critical ways. (For example: ‘You feel as though you are being pursued by secret agents. I don’t really know much about secret agents. I am familiar with psychological processes, though, and I believe that you are suffering a delusion.’) It is important not to leave the para-positioning of one’s own viewpoint, and to always stay appreciative and respectful of the other person’s reality. The client’s sensus privatus is neither questioned nor commented upon. One’s own sensus privatus is introduced, as well as an implicit further sensus: namely, that the therapist can respectfully accept multiple different viewpoints side by side. Still, the possibility of recognizing multiple viewpoints is a sensus privatus of the therapist – in subsequent therapeutic sessions, it can, however, become a consensus communis between the two people. At present, however, this is not possible for the client. With subjective certainty he considers only his own viewpoint on his circumstances as the sole possible reality.

The sense in the attitude of para-position lies in the ability to remain authentic without having to pass judgment on the viewpoint of another. One’s own clear stance and open communication of it can convey security, which can be experienced as fear-reducing. Reducing fear is an important prerequisite for successful relationship building. A realistic perception of one’s counterpart and of the quality of the relationship is only possible if the person can more congruently symbolize his experiences without distortion from fears (see: Rogers, 1959 p. 204).

Fears in therapy

According to the abovementioned considerations regarding pathophysiology and the resultant conclusions, the goal of therapy is to establish a positive, authentic relational experience of such quality that the emptiness and deficit of relationship is filled. The client’s various fears make the building of relationship more difficult, however. These fears should be more precisely illuminated.

Clearly the fears related to the client’s delusional content must be considered first. Clients who suffer prolonged delusional impairment and tend to integrate their fellows into their delusional system as further figures who wish them harm will also quickly assign their therapist a position within their delusional construct. These fears are accessible and able to be reformulated by the client. (For example: ‘I suspect you’re also from the secret agency.’) Communicating in a way that leaves little room for other possible interpretations can impede this process. The therapist who clearly presents his standpoint offers a smaller projection surface for fantasies and mistrustfulness.

A second fear of the client’s is less accessible to him, but appears in therapy as a persistent obstacle to relationship building. Carl Rogers writes: ‘Once the acute psychotic behaviors have been exhibited, a process of defense again sets in to protect the organism against the exceedingly painful awareness of incongruence’ (Rogers, 1959, p. 230). Therapy would ultimately lead to a perception of incongruity. ‘Anxiety is the response of the organism to the “subception” that such discrepancy may enter awareness, thus forcing a change in the selfconcept’ (Rogers, 1959, p. 204).

Finally, the third and most threatening fear that must be dealt with in the therapeutic process is that which first initiated the cause of the organism’s delusional reaction. The fear of becoming aware of the full scope of one’s own abandonment, of feeling not understood, of not being valued. It seems obvious that it is hardly expedient for the therapist to fuel this fear through psychologizing statements like, for example: ‘You are delusional because you are lonely.’ This kind of didactic approach is not helpful to the therapeutic process and would contradict a respectful para-position. Furthermore, there would also be a danger of activating that which Rogers calls ‘subception’: ‘[…] whereby the organism is forewarned of experiences threatening to the self’ (Rogers, 1959, p. 206). This would result in defense mechanisms which counteract further therapy.

Each of these outlined fears are viewed by the organism as a threat and trigger defensive behavior. The goal of the organism would thus be to avoid any threat to the self (see: Rogers, 1959, p. 204). The organism could achieve this through ‘[…] perceptual distortion of the experience in awareness, in such a way as to reduce the incongruity between the experience and the structure of the self’ – this would be, for example, the integration of the therapist into the delusional construct. Or, the organism can keep the experience at a complete remove from his awareness – this would be enabled by an internal psychological process, or, more simply, by the client’s staying away from therapy.

In order to avoid fueling the client’s fears, it is useful to again mention the importance of an attitude that is clear and open, emphasizing one’s own standpoint without questioning the subjective reality of the client. This enables an authentic encounter without threat for the client. ‘When the individual is in no way threatened, then he is open to his experience. To be open to experience is the polar opposite of defensiveness,’ writes Rogers (Rogers, 1959, p. 206). It is thus possible in therapy for the client, without defensiveness, to allow new relational experiences which will ultimately prove beneficial to him.

Appreciation of another person’s view

The appreciation of another person’s view of reality will ideally lead to the other person appreciating one’s own perspective. In light of mutual appreciation, a relationship based on honesty and equality is the means and goal of treatment. Carl Rogers writes: ‘To be a companion to my client as he or she explores the hidden mysteries of the inner life and to view that inner life as an acceptable part of reality – these are two of my chief goals in being a therapist’ (Rogers, 1985, p. 43). But precisely with regard to obviously unrealistic delusional content, the problem of insufficient appreciation of the client could arise in the process of relationship building. The therapist could appear as an assessor of the unreality of the person’s delusional content. The therapist could find himself in the role of one who knows, one who knows better, one who considers himself superior, as though his perception of reality is more real, complies with the sensus communis, and is therefore more valuable. As there is a particular danger of evaluating the person’s delusional content in a derogatory way, the therapist must pay particular attention to maintaining respect for the person’s view.

Truly honest, authentic contact hardly seems possible without referring to the reality of the other person. If one were to deliberately exclude the other person’s views in the encounter, there would be a risk of digging in one’s heels as a silent ‘know-it-all’; or, at least, being perceived as such. This stands opposed to an honest, real relational experience. Here again, the taking of a conscious para-position is helpful.

The declaration of one’s own views of reality more or less also implies an awareness that the other person has a different view of reality. (‘You feel persecuted. That is your view. I think that you are suffering an instance of delusion.’)

Even if it seems severe to confront the client with one’s own view of events, more possibilities lie in this approach. The therapist appears not as the mute observer, as the specialist who actually knows better, taking the client into consideration and silently protecting him from confronting reality. Such a perspective on the relationship would degrade the client to a figure who is ignorant and in need of protection, and emphasize the position of the therapist as the knowing specialist so powerful that he must and can protect the client. An eye-to-eye therapeutic encounter would be impossible with this approach. Perhaps, through communicational behavior such as this on behalf of the therapist, the client would come under increasing pressure to have to free himself from this incapacitating position, and emphasize himself and his views as more important and meaningful. It is conceivable that an intensification of delusional symptoms could result.

Through the open declaration of one’s own views, the therapist enables an encounter of mutual respect on equal footing. The therapist does not regard the person as an incapacitated patient who must be protected in such a way that he cannot be trusted to handle the truth. On the contrary – the communication of the therapist’s views reflects an appreciation of the client, a confidence that he knows how to handle the therapist’s views. (The therapist’s implicit message would be roughly: ‘I’m offering you my viewpoint, and trust your ability to handle it.’) At first, the client’s interaction will probably tend to be characterized by delusion, not perceiving the other person’s viewpoint. But subsequently a different viewpoint can increasingly gain importance.

Respect is also reflected in the fact that, due to a mistaken understanding of professional behavior, the therapist does not remain an impersonal handler; but rather comes to be seen as a person with his own opinions and views in the relationship. (As if he should say: ‘I value you so much that I’ll show you something of mine.’)

Carl Rogers writes: ‘The more the therapist is himself or herself in the relationship, putting up no professional front or personal façade, the greater is the likelihood that the client will change and grow in a constructive manner’ (Rogers, 1986, p. 197). The importance of truly real, direct interaction with each other cannot be valued highly enough – especially under the assumption of a deficit in perception of congruent relational experience as the cause of the extant disorder.

Empathic understanding

Empathy represents a particular challenge in relationship building in therapy. A willingness to understand delusional content must fail, above all, when it comes to unrealistic delusional content. Too deep an absorption in delusional content harbors the risk that communication with the therapist will be experienced as strongly delusion-centered, and the therapist will be increasingly associated with certain delusional content. The danger that the therapist will be integrated into the delusion seems increasingly likely.

Pursuant to the conclusions from the pathopsychological model, a confrontation with the delusion would be considered only a confrontation with its symptoms. A treatment approach that would want to intervene closer to the origin of the disorder should keep positive regard the focus of therapy. Positive regard seems, however, hardly possible with regard to delusional content.

In trying to understand delusional content that is quite contradictory to reality, an inner contradiction will arise within the therapist as he makes an unavoidable comparison with his own perception of reality. (Statements like, ‘The relay station through which the secret agency transmits secret messages to their sub-agents is in my brain’ are difficult to comprehend. With his view of reality, the therapist will evaluate them as improbable.) Here, too, a clear para-positioned standpoint seems helpful. In the emphasis of one’s own views, there must be no evaluation concerning the view of the other person. But empathic understanding seems so difficult.

Empathic understanding of the feeling of being misunderstood and the fundamentally lonely living situation of the client is initially impossible, because these emotions will not be accessible to the client. Indeed, fending off the profound realization of being misunderstood is precisely the creative process of delusion. Those emotions which arise from the delusional experience are, however, very much accessible to the client. (For example: ‘I’m afraid of the secret agency.’)

Here a related point emerges, at which empathic understanding is unconditionally possible. (For example: ‘When I see how threatened you feel by the secret agency, I can really understand your fear.’) Emotional understanding does not mean that the therapist agrees with the reality of the delusional content. With regard to the content, the therapist maintains his clear stance. He can, however, in comprehending the other person’s view, still feel and express in accordance with his emotional understanding. Rogers formulates this principle as follows: ‘To sense the client’s private world as if it were your own, but without ever losing the “as if” quality – this is empathy, and this seems essential to therapy’ (Rogers, 1961a, p. 284). Empathy is possible and beneficial not with regard to delusional content, but in an emotional respect. Empathic understanding should be attended by acceptance. ‘Acceptance involves the therapist’s willingness for the client to be whatever immediate feeling is going on – confusion, resentment, fear, anger, courage, love, or pride. It is a nonpossessive caring’ (Rogers, 1986, p. 197f).

Perhaps the client’s experience of his environment has, as yet, been primarily a feeling of not being understood, based on other people’s perception of his delusional content as obviously absurd. Perhaps he has only ever been corrected or even rejected. Now his experience in therapy is to know how it feels to be understood, with all of the worries and fears he is now aware of, and with all of the burdens that arise as a result of the delusional content of which he is subjectively certain. This first experience of being understood in therapy is not only a part of the healing process and ultimately aims to fill the emptiness – the vanitas in truly being understood – which would be identified as the cause of the disorder. The feeling of truly being understood also strengthens the relationship between client and therapist in a way that will consequently allow the therapist to formulate his views more clearly. Because the client feels emotionally understood exclusively in this relationship, the therapist will become a significant counterpart. This is the prerequisite for the therapist’s crucial step of bringing up the sensus communis in order to propose the possibility that the realities of others exist alongside the reality of one person. Were the therapist not an understanding and, in turn, significant person, his views would hardly be of interest to the client. The key to successful treatment of delusion is the relationship that empathically addresses the emotions of the client in an honest and respectful way. Person centered therapy can represent an especially beneficial approach to treatment in this regard.

Consensus communis

Under the assumption (which is to be drawn from pathophysiological considerations) that delusion may be predicated upon a deficit – a vanitas – of beneficial relational experiences, delusion ought not to be regarded as a disorder, but rather as an attempt by the organism to activate counterregulation mechanisms. Psychotherapeutic treatment holds honest and real relational experience as its objective. In order to face the dangers and peculiarities of building a relationship in the shadow of a delusion, the psychotherapeutic attitude of para-positioning is advisable. This attitude provides for the possibility that more than one viewpoint on reality can respectfully coexist. With the increasing importance of the therapeutic relational experience, the therapist becomes a more important person in the eyes of the client. The therapist’s viewpoint will also become more important to the client. The therapist’s attitudes, views, and his approaches to potential problems are observed by the client and increasingly regarded as relevant. The therapist’s approach – one which accepts the subjective reality of another person – can, over the further course of therapy, assist in encouraging the ability of the client to also acknowledge more than one perspective. Counter-argument and a desire to convince the client cannot resolve delusion. ‘Subjective certainty’ is, in its sensus privatus, not changeable. However, by introducing a sensus communis – namely, the consensus that there can be different views of reality – a softening of the strict delusional position can be effected. The therapist must not actively want to bring about this consensus. It occurs in the course of an intense relationship. Yet this crucial step in treatment requires so much successful relationship building that the therapist meanwhile becomes an important relationship to the client, who also values the therapist’s views as increasingly important. (For example, the client could express the following: ‘I know you believe I’m delusional, but the way I see it, secret agents are threatening me.’ Although the client still holds fast to his sensus privatus, he already perceives that his counterpart has another view and he respects it. The subjective certainty of the only possible explanation of reality is beginning to soften.)

Through experiencing this consensus communis the client succeeds in increasingly freeing himself from his sensus privatus. Through the experience of valuable relationship, delusional self-will loses meaning, can fade into the background and dissipate. In the therapeutic relationship the client is successful in having the experience of being truly valued by someone else, and having meaning as a person. This is the healing process. The client is enriched overall; the void of valuable relational experience is remedied.

Additional information

Notes on contributors

David Oberreiter

David Oberreiter is a psychiatrist. He is director of the Institute of Psychotherapy of the Kepler University Hospital in Linz, Austria. His clinical work in the division of psychiatry indicates concrete concepts to build beneficial relationships with persons suffering from severe psychiatric disorders.

Notes

1. See ICD-10: F20, F22, F23, F24, F25, F30.2, F31.2, F31.5, F32.3, F33.3, etc. (World Health Organization, 1992)

See DSM-5: Schizophrenia Spectrum and Other Psychotic Disorders, Bipolar Disorder, Major Depressive Disorder, etc. (American Psychiatric Association, 2013).

2. cf. ‘Vanitas,’ emptiness, nullity.

3. Vanitas has been chosen as a self-contained word in order to linguistically emphasize the particular meaning of emptiness. The Latin word ‘vanitas’ can be found in the classical Latin literature of Cicero, Livius, Petronius, Plinius, Sallustius, Seneca, Tacitus and others. It is employed in the sense of nullity, trace, emptiness, falsehood, and also as empty semblance and vanity.

4. The imprecision in the spelling of the word ‘sensus communis’ is rectified in the 1800 s edition (see Kant, 1800, p. 151). Starting with the 1820 third edition, the spelling of the word ‘sensus privatus’ is also corrected (see Kant, 1820, p. 150).

5. “1. die außergewöhnliche Überzeugung, mit der an ihnen festgehalten wird, die unvergleichliche subjektive Gewissheit. 2. die Unbeeinflußbarkeit durch Erfahrung und durch zwingende Schlüsse. 3. die Unmöglichkeit des Inhalts” (Jaspers, 1913, p. 45).

6. Feminine and masculine pronouns used in this article refer to individuals of any gender identity.

7. Issues regarding the mind–body problem would go beyond the constraints of this article. (See Gendlin, 1997, 2000; Stein, 1917; pp. 40 ff. and others).

8. Vanitas of relational experiences can be read as emptiness (to be nonexistent) and as nullity, empty appearance of relational experience, namely in the sense of genuine relational experience that is present, but insufficient. Here it may be read initially as meaning ‘emptiness.’