“Reality testing” is a distinction that is in the background of Matthew Ratcliffe’s penetrating and incisive book Real Hallucinations: Psychiatric Illness,

Cover art: Real Hallucinations by Matthew Ratcliffe – so what are fake hallucinations? Find out here

Intentionality, and the Interpersonal World(Cambridge, MA: MIT Press, 2017, 290 pp.). Disturbances of the sense of reality are among the key phenomena that cause people who suffer from hallucinations or delusions to be referred to psychiatrist professionals.

 Ratcliffe takes pains to work through the various senses of reality that confront one as soon as one wishes to assert that something = x is not real. For example: “Illness or jet lag can involve an all-enveloping and lingering sense of one’s perceptual experience as somehow lack, not quite right” (p. 44). But that is just the beginning.

 The memoires of psychiatric patients, who have survived psychosis – as well as thought experiments invented by philosophers and Ratcliffe’s own survey research – are full of examples where the distinctions between perceiving, imagining, remembering, anticipating, and experiencing, begin to break down and actually do break down. All these are engaged in the narratives of those who have survived psychosis such as Elyn Saks, M. Sechehaye, or reports from a survey collected by Ratcliffe.

 Ratcliffe collects extensive evidence of the intermittent flexibility of the boundary between imagining that something happened and remembering that something happened; between intending to fill up the gas tank of the car and remembering that I did so (but did not); between perceiving the bear at the window of the cabin and imagining the bear at the window, and so on. I look into the mirror and see a face that does not look anything like my own (my example, not Ratcliffe’s). The face is so different that I realize I must be dreaming, and wake up. If I do not wake up, and the face still looks frighteningly different, then modes perception and imagination have gotten mixed up, I am having a psychotic breakdown and need help.

 These considerations result in Ratcliffe’s innovative account of hallucinations and delusions. Ratcliffe’s nuances, conditions, and qualifications are many, but they boil down to: in hallucinating, content is framed using an intentional mode at variance with what it might be anticipated to be. Thus, a voice that is remembered or imagined is misconstrued as being actually perceived in the here and now; in delusions such as thought insertion, a thought that is imaginary or remembered or otherwise fictional is misframed as an occurring belief. The misframing, slippage, or “going off the rails,” occurs because of an anxious anticipation of something = x, including the possibility that what the individual is fearing is fear itself.

 This account finds strong support in the works of R. Bentall, L. Sass, and the reports of survivors of psychosis, distinguishing between hallucinations as having an experience versus having a sense of an experience. (The reader may usefully consult the book itself for the excellent bibliography.) In hallucinating, one is having a “sense of an experience.” And, notwithstanding the insistence of the psychotically disturbed that they are really experiencing what they are experiencing – which is what makes it so frightening – a moment often comes in which the [psychotic] individual acknowledges he or she can distinguish the voices or anomalous beliefs from everyday, standard situations, places, and practices.

 This leads to what is sometimes described as “double bookkeeping” – the psychotic person seems to inhabit two worlds – the standard, shared world and his own special, different one. Or the psychotic person may feel that the standard world has been completely annihilated and he is the only survivor or feel that he is already dead. In either case, the individuals looks carefully both ways before crossing the street. Curious. Yet this is the disorder itself.

 Ratcliffe also finds support in the work of Marius Romme and Sandra Escher, who are credited with giving rise to the Hearing Voices Movement (p. 30 – 33). This is not just a theory or collection of data, but a normative position about how those who have anomalous experiences such as hearing voices should engage with their voices and engage with the medical community. In so far as I understand it, Ratcliffe is a fellow traveler with the view that voices with distressing content are socially embedded and events such as trauma, neglect, abuse, adult social isolation, and so on, are important determinants of the anomalous experience.

Often the disordered individual’s sense of reality is demonstrably in breakdown, but differences and variations in the degree of disorder are of the essence in description, diagnosis, and treatment.

 You and I – as average ordinary everyday citizens – have trouble communicating with psychotic individuals because we no longer share the same methods or procedures for reality testing. The psychotic’s reality testing is producing a different result than yours and mine. The result may be so vastly different that we say the psychotic has no sense of reality at all. None. The individual is banging his head against the wall. However, fortunately, that is rarely the case. Most often a form of “double bookkeeping” is occurring, and sense can be made out of the seemingly senseless.

 This is where Ratcliffe’s powerful contribution comes into its own and makes a difference. Inquiring minds want to know: what the heck is going on with hallucinations and delusions such as thought insertion?

 Ratcliffe’s contribution is an important, even outstanding one; but this reviewer is at pains to create a context for a review that will connect with the prospective readers.

Yet another digression must be bracketed before one can engage the book in context and on its own merits.

 To be sure, the biological explanation of hallucinations and delusions looms large. But Ratcliffe does not go there, and the reader will find none in this text, though their appropriate applicability is acknowledged. The conventional wisdom is: dopamine up, hallucinations up. Take a bunch of cocaine. Do this enough (or sometimes only once) and the brain is flooded with dopamine (and related, activating neurotransmitters). The person is hearing and seeing all sorts of stuff that is not really there. We call this stuff = x “hallucinations and delusions.”

 This neurotransmitter imbalance explanation is evidence-based and pharmacological interventions that reduce the ratio of available dopamine to dopamine-receptors really do seem to restore equilibrium to the brain.

 However, something seems to be missing from the neurological discussion – an account that puts the suffering, struggling human being in a personal world that is able to support and sustain his recovery and return to humanity. Hence the need for Ratcliffe’s contribution, which lays the foundations for such a conversation (without, however, actually completing the journey).

 Ratcliffe’s account begins by taking issue, cautiously, with Dan Zahavi’s (and other’s) approach to the minimal self. Key term: minimal self. At the risk of oversimplification, psychosis is then hypothesized to be a disorder of the integrating and synthesizing capabilities of the minimal self. Ratcliffe generally endorses what Zahavi has to say but is at pains to include the requirement that the minimal self emerges out of a social matrix: “Our most basic sense of self is developmentally dependent on interactions with other people” (p. 16). Thus, when the social milieu is disrupted – through trauma, adverse childhood experiences, metabolic disorders, or addiction – the minimal self and its meaning making and integration capabilities also break down. Viola! Psychosis.

 How minimal is the minimal self, asks Ratcliffe? He answers that it includes the sense that the individual is having a pre-reflective sense of “mineness” in perceiving, imagining, engaging in inner speech, moving around in the space, and remembering.

These immediate prereflexive, unproblematic acts of seeing, imagining, verbal thinking, moving, and remembering are called “modalities of intentionality” in the phenomenology of Edmund Husserl. These acts of intentionality have a temporal form. Anticipation is one of the fundamental forms of intentionality along with retention (recollection) and being present. (Note this material is technical and not for the faint of heart, but will be of interest to many readers.)

 This analysis of intentionality opens up deep philosophical issues at this point, and Ratcliffe engages with them. The bottom line for Ratcliffe is that an intentional analysis of consciousness is on the critical path to providing an account of hallucinations and delusions. 

For example, is the intentional act of seeing distinct from the content of consciousness? Can an individual disentangle the sense of seeing a tree from the shape, color, location in space, and so on, of the experience, leaving us with access to an act of perceiving in itself? Is the form separable from the content? It seems that it is, though their togetherness is such that one can only get access to the form through and by means of the content.

 Since this is not a softball review, one may ask: So what? Hard working, dedicated, committed psychiatrists are taking arms against a seeming epidemic of psychotic disorders using the tools with which they have been trained – second generation anti-psychotic drugs. If a person comes in claiming to hear things that are not there and the person does not have a metabolic disorder, then the doctor is probably going to err on the side of caution and start him on a low does of one of those anti-psychotic medications. So why do we need a phenomenological analysis of real hallucinations – and “real hallucinations” as opposed to what? Fake hallucinations? 

It turns out that, for the most part (and absent a study such as Ratcliffe’s and a few others like it), we do NOT know what hallucinations are. Even more problematically, we think we know, but we do not. We may usefully take a step back here to put the matter in context. 

 The average person, for example, thinks of hallucinations the way they occur in the Hollywood movie A Beautiful Mind (my example, not Ratcliffe’s). In the movie, the Nobel Prize winning mathematician and economist John Nash is having a conversation with his roommate. The audience sees the roommate, hears him and Nash talking together, and the scene is portrayed as if Nash sees and relates to the roommate the way we, the audience, see and relate to him.

Ratcliffe does not mention the Nash movie, and I bring it up to relate Ratcliffe’s contribution to the average, everyday misunderstanding of hallucinations. This academy award-winning movie about Nash contains many compelling performances, much engaging narrative, a good example of an elaborate, delusional system, but what it does NOT contain is an example of a real hallucination. (By the way as regards Hollywood fictions, The Black Swan (2010) with Natalie Portman does a much better job of capturing what psychotic hallucination are like as the lace of a ballet costume seems to grow like a malevolent fungus.)

Nash’s roommate does not exist – the audience eventually learns (to their astonishment) that the roommate is a hallucination. The roommate is part of Nash’s elaborate delusional network, resulting in Nash’s being given a diagnosis of paranoid schizophrenia – along with electroshock therapy and first generation antipsychotics (but that is another story). Meanwhile, if one gets inside the experience of the person who is having conversation with someone who is not really there, the experience is nothing like an ordinary experience. Okay, so what is it like? Hollywood gives us examples of fake hallucinations. Hence, the need for Ratcliffe’s Real Hallucinations.

(c) Lou Agosta, PhD and the Chicago Empathy Project