A talk with psychologist Richard Bentall, author of the well known book “Madness Explained: Psychosis and Human Nature,” which is an examination of the psychological causes of the symptoms associated with psychosis, schizophrenia, mania, and other mental issues. Richard Bentall is a Professor of Clinical Psychology at the University of Sheffield.
A transcript of this talk is below. Topics we talk about include: the experiences and mental struggles that can lead to symptoms associated with psychosis and other mental illness; how theories of mental illness have changed over time; pushback and criticism of psychology-focused explanations of mental illness; aspects of madness that most of us experience at some point; the role of feelings of isolation in madness; the difference between beliefs and delusions; and my own mental struggles as a young man.
Episode links:
Resources discussed in this episode or related to the topic:
- Richard Bentall’s book Madness Explained
- Bentall’s University of Sheffield professor page
- Richard Bentall’s Wikipedia page
- 2021 Guardian article about Bentall’s life and work
- Bentall’s book Think You’re Crazy? Think Again: A Resource Book for Cognitive Therapy for Psychosis
- Article about Acceptance and Commitment Therapy (ACT), mentioned in talk
- A previous podcast episode about psychosis and so-called schizophrenia
- A previous podcast episode about anxiety
- A previous podcast episode about existential psychology
TRANSCRIPT
Zach Elwood: Hello and welcome to the People Who Read People podcast with me, Zach Elwood. This is a podcast aimed at better understanding other people, and better understanding ourselves. You can learn more about it at behavior-podcast.com.
On this episode I interview the psychologist Richard Bentall about mental illness, psychosis, and so-called schizophrenia. Bentall is probably most well known for his 2004 book Madness Explained, which is a fantastic book that I highly recommend. It won the British Psychological Society Book Award, and is widely regarded as a groundbreaking work in the world of psychology. When it comes to psychology, for me personally, it’s up there as one of the most important books ever written, alongside Irvin Yalom’s Existential Psychotherapy.
In that book, and in his work in general, Bentall attempts to show how various symptoms of so-called madness are understandable human responses to various forms of stress and anxiety and trauma. In other words, he focuses on the psychological causes of madness, the factors related to the workings of our minds, as opposed to potential biological causes.
In this episode, we talk about how theories about the causes of mental illness have changed over time; we talk about pushback and criticisms to psychology-focused theories of madness; we talk about how it is that mental stresses can result in madness; and we talk about how we might distinguish strange but fairly common beliefs from delusions.
Along the way, I also talk about my own mental struggles as a young man; If you’re interested to hear more about that, I recommend a previous episode where I talked to Nathan Filer about psychosis and schizophrenia. And if you’re interested in mental health topics in general, you might also like a talk I had with Scott Stossel about understanding and dealing with anxiety. I also have a talk about existential psychology and therapy with the psychologist Kirk Schneider.
A little more about Richard Bentall: he’s a Professor of Clinical Psychology at the University of Sheffield. In 1989 he received the British Psychological Society’s May Davidson Award for his contribution to the field of Clinical Psychology. He’s written several books, including “Doctoring the Mind: Is Our Current Treatment of Mental Illness Really Any Good?”, and one titled “Think You’re Crazy? Think Again: A Resource Book for Cognitive Therapy for Psychosis.” A 2021 Guardian article about Bentall was titled “Richard Bentall: the man who lost his brother – then revolutionized psychology”, and it’s a good read if you’d like to quickly learn more about his work and life story.
Okay, here’s the talk with Richard Bentall.
Hi Richard, thanks for coming on.
Richard Bentall: Hi. It’s good to be here.
Zach: So, maybe we can start with the idea that symptoms of so-called madness; the idea that those symptoms can be explained by psychological processes is seen by some people as controversial. And I know that when you first started writing about these kinds of ideas which I think was back in the ’80s you started some of this work, those ideas were more controversial than they are now. Maybe you could give an overview of how the mental health field as a whole has their views of such ideas has changed over time and some of those ideas have become more accepted.
Richard Bentall: Yeah. Okay. That’s actually quite a big topic but I’ll try and deal with the highlights, really.
Zach: Yeah, that’s a big one.
Richard Bentall: So throughout most of the history of psychiatry, research into mental illness is focused on diagnostic categories. So, people have been divided into different groups of patients according to whether they have a diagnosis of schizophrenia, a major depression, or whatever. And that seems superficially quite a sensible thing to do, it’s an idea which goes back at least to the work of Kraepelin in the latter half of the 19th century. So for most research studies, for example, people are divided. You find that there’s a target group of patients who have particular diagnosis, say schizophrenia, versus healthy people who don’t have a diagnosis, and also sometimes a control psychiatric diagnosis. So you might have three groups; you might have schizophrenia patients, depressed patients and controls, and the hope is to find out something about schizophrenia. Of course that’s built on the assumption that the people who have the diagnosis of schizophrenia all have something in common, which makes them different than people in the comparison groups.
And quite early on in my career, it came to me. It wasn’t a particularly original idea, I don’t think. I can think of other people who said things to me which made me think along these lines but it came to me that schizophrenia in particular wasn’t a coherent entity where that assumption could be upheld. In fact when you looked at people who had diagnosis of schizophrenia, they had a wide range of different types of symptoms. And therefore it wasn’t really all that surprising that almost every variable known to influence human behavior at some time or other had been held out as a potential causal factor in schizophrenia, but for none of them it did it seem that the evidence was particularly consistent. That’s exactly what you get if you compared people who according to diagnoses, which were actually masking a great deal of heterogeneity within the diagnosis. So I wondered what you could do about that and the thought came to me that maybe if we couldn’t decide on what the core features of schizophrenia were, we could certainly agree on who, for example, had auditory hallucinations and who had paranoid beliefs. So I started to do research in the mid 1980s which was targeting people just based on those particular symptoms. Initially I started looking at people who were experiencing hearing voices. I was a bit influenced by my PhD which I’d actually done before my clinical training, and which was nothing to do with schizophrenia but it was actually about various aspects of child development, but was very influenced by the ideas of a Russian psychologist called Vygotsky who was interested in the way that children learn to think in words, a process which culminates in what you call inner speech– we all have this inner dialogue in our head. And it occurred to me that, whoa, whatever’s going on in auditory hallucinations is got to be something which is related to that process. And that led me fairly quickly to the idea that when people hear voices, what they’re actually hearing is their own inner speech or inner voice which they are somehow failing to recognize as belonging to themselves.
So while I was still in clinical training, I carried out my first study of hallucinations to test that hypothesis and actually I generated a result which has been replicated many times since. I think it’s probably my most replicated study, although the way I carried it out back in the day involved some very crude technology compared to the techniques which we have available today. But anyway, from there I went on to think about, well, what could lead people to have paranoid beliefs and so on? And that whole kind of approach became this idea of trying to develop a separate understanding for each of the different symptoms. And the idea is that once you’ve explained each of the symptoms, there’s no schizophrenia left to explain. Once you explain why people hear voices, why they have delusions, why they have what we call thought disorder which is actually a sort of speech disorder, why they have the so-called negative symptoms which is the ones which are associated with loss of motivation and loss of feeling… Once you explained those with separate theories for each of them, there’s no schizophrenia left to account for. And you’re right, it was a fairly controversial idea early in the day. People, I think, varied in terms of the way they responded to it. A lot of the psychiatrists I actually worked with at the time, because I was involved in face-to-face clinical work at the time, I think they thought I was kind of nice but useless– like somebody who had wacky ideas but they didn’t see me as certainly not harmful to put it like that. Whereas some people in the psychiatric establishment, senior people who got very annoyed about the suggestion that schizophrenia wasn’t a coherent entity and they got quite hostile, I would say at times. But as time rolled on more and more psychologists and physicians started to focus on symptoms. I wasn’t the only person I’m sure who kicked off this movement, other people at roughly the same time had also begun to look at individual symptoms. And we’re now in a position where research on symptoms is very well established. It’s a huge industry, in fact. In fact I find it almost impossible to keep up with it.
There’s a lot of research on particularly hearing voices, hallucinations, and there’s a lot of research on paranoid delusions, less research on some of the other symptoms, but it’s still there. So it has become quite widely accepted. And when I first started in that area, my methods were psychological ones because I was a psychologist obviously. But the borderlines between psychology and biology have dissolved in those three decades largely, mainly due to the invention of advanced neuro imaging techniques particularly MRI. Which means that psychologists can now carry out psychological tests on people and at the same time see what’s happening in the brain while people deal with those tests. So you can see using a technique, functional magnetic resonance imaging which I’m sure you’ve heard of. You can see which parts of the brain are active when a patient tries to solve a particular type of problem, for example, and then you can compare the brain activity in patients to other people. But again, you can do that kind of research focusing specifically on symptoms. And so I don’t think it’s controversial anymore to do research on symptoms. It’s still to some extent controversial, the idea that schizophrenia isn’t over meaningful a concept in the way it’s been traditionally used. But even that has become much less controversial in the sense that there are prominent people in main stream psychiatry who would argue that certainly the diagnostic system is not fit for purpose and that the concept of schizophrenia in particular is problematic. And that’s led in the last 10 years to a number of efforts to try and think of ways of developing better ways of classifying patients.
So, just an important point to add here and then I’ll stop for your next question. The important point to add is that there are some people who don’t like the idea of classifying patients at all. They think that somehow it’s dehumanizing, objectifying, and that each patient is unique. Of course it’s true that in many ways each patient is unique, but in order to make progress scientifically and also in order to have some pragmatic ways of estimating for example how many people are likely to need psychiatric treatment at any particular time in history, which is an important issue for public health people, or in order to find out for example which drugs are going to be most effective for which people, you do need to have some way of putting patients into groups to find groups which are meaningful.
So I think where we are now is that people accept there’s a very widespread acceptance that, for example, the Diagnostic and Statistical manual of the American Psychiatric Association, the only positive thing to be said about it is that it’s pragmatic and easy to use, but nobody really believes that the categories in the DSM correspond to how nature is.
And there’s quite a lot of search going on for alternatives. There’s some big research programs trying to develop alternative ways of thinking about those of classifying psychiatric conditions.
Zach: So it seems like some of the initial pushback in the– a few decades ago anyway some of that pushback about thinking about the psychological aspects of psychosis and schizophrenia might be seen to be due to some of the more irresponsible psychological theories that happened before that, like the idea of the schizophrenic mother. So I’m curious, do you see that as at least accounting for some of the reason why people didn’t want to delve into some of the psychological aspects of it?
Richard Bentall: Yeah, so it certainly, I think that’s true that if you look at some of the theories you should propose in the 1960s, which tended to put, I think where blame is actually, right. In fact, they tend to locate the blame for the problems of young adults on squarely on parents who were sometimes described in ways which make them almost seem like monsters, the refrigerator mother, for example. So when psychiatry took a biological turn in the 1980s, one of the reasons for that industry was that people thought that somehow that biological theories were less stigmatizing. Actually, they thought that somehow, that if you said that somebody who had schizophrenia had a brain disease, you were saying it was neither their fault nor the fault of anybody in their family.
And a lot of what was at the time called mental health literacy campaigns were based around that idea. And people used phrases like it’s a disease like any other or sometimes you’d hear people say, in fact, you see clinicians saying to patients, you’ve got something a bit like diabetes. It’s a chemical imbalance, I’m afraid like a diabetic person, you’re going to have to take your drugs for the rest of your life. But that’s what’s happened. And actually the situation around that is actually quite complex and nuanced. So what’s emerged is that a lot of evidence emerged that family relationships do affect the development of mental illness in offspring in children who later go on in adulthood to develop psychosis. I don’t think there’s any doubt about that now, and I’m always very careful, however, about how I talk about it, because in my entire clinical career, and I should just say as a caveat that I’ve not been doing face to face clinical work for about 10 years, but I did quite a lot over the years. In my entire career, I don’t think I ever met the parents of a psychotic patient who was a monster.
Actually, they seemed to be very distressed people whose hearts were broken very often by seeing their sons and daughters undergo these profound difficulties, which were, that you could see the grief sometimes in parents, as they could see. Every parent wants their children to have a bright, wonderful, happy future. And to have that stolen, as it seems, by this whatever it was, nobody really understood it. Schizophrenia, it was breaking their hearts. Sometimes it was leading them to do things which actually made things worse. So, this is where we come to the idea of expressed emotion. So, here’s quite a lot of research which shows it’s probably one of the most well demonstrated things in psychiatry. The way that a parent reacts to a child’s emerging mental illness can affect the course of that illness as it goes on.
Particularly if the parent is hypercritical or over controlling, then that tends to mean that the mental illness will persist and will be much less likely to resolve. The thing about that though, is that if you think about those two characteristics of the parents being critical and over controlling, I mean, which parent, in all honesty can say they’ve never done that. I’ve got two kids and two step kids, and I know that I’ve failed to meet my own standards of parenthood on quite a few occasions to be fair to myself, when driven to distraction by teenage behavior. So everybody does those things to some extent. And the other thing about them is that, of course, people sometimes do them more when they see their children in trouble. If you see a child who’s constantly somehow making bad decisions or it looks like they’re making bad decisions, the temptations become highly critical.
Or if you feel guilty about the fact that they’re developing psychological problems and you think, “Oh my God, what have I done to cause this?” Then of course you’ll be over controlling and overprotective. So parental behavior does have an influence on the emerging mental health symptoms of children. There’s absolutely no doubt about that. But often it’s not always because parents do bad things. Sometimes they do bad things for sure, but it’s always for that reason. Sometimes it’s parents trying to do their level best in a way which is actually making things worse.
Zach: These things are just so complex. And I think, there’s often this tendency to look for these simple narratives of good and bad, but it’s like narcissism too. We all have narcissism, we’re all narcissistic in a sense, and we sometimes, even the best of us can behave in narcissistic ways in certain situations, and these certain complex things unfold. And I think that’s what to remember about, that becomes a destigmatizing thing about this, thinking about the psychological aspects, it’s like these are such complex processes and systems and people’s minds can go down rabbit holes. I think of my own experiences where it involved smoking a lot of marijuana when I was in college and leading to me having my mental issues and dropping out of college. And that’s just one factor. And I think when people tend to look for these simplistic narratives about things.
Richard Bentall: Yeah. So I mean, what the research tells us is all these different things interact. So marijuana’s the kind of interesting one. Lots of social circumstances which push young people to take marijuana, and actually most young people try it to some degree, but for some people we know, I think we’re pretty certain high degree of certainty but it’s very bad for them. It produces psychotic reactions. But there are all sorts of social circumstances which will tend to make somebody more likely to take marijuana. And if they do take marijuana, to take it frequently and to use for self me medication. And those might include biological factors, of course, it could be that there’s some genetic, I don’t know, any research you suggest it, but it wouldn’t surprise me that some people are got more for whatever reasons, might have a genetic tendency to put themselves in that situation, if I can put it like that. We don’t know but it wouldn’t strike me as weird if it turned out that that was the case.
Zach: A small note here, if you’re someone who hasn’t heard about the link between marijuana and mental issues and thinks that might be an exaggerated connection, I’d invite you to read up on that connection. There’s a lot of research and writing on it. For what it’s worth, I actually still smoke marijuana occasionally, so I’m definitely not anti-marijuana. But for me personally, I believe it was an amplifying factor in my mental breakdown as a young man in the same way that it seems to be a contributing factor in many case studies you can read. I think I was predisposed to some bad outcomes due to me already being a very anxious young person who had previously suffered panic attacks in high school and such. And in my case, I think it was less about trying to self-medicate than it was about me wanting to feel cool and fit in despite being very unhappy and anxious.
And also, I think some young people can be quite fragile because they haven’t developed a strong sense of self and models of the world to think about marijuana as that it can really amplify our visceral sensation of things in the same way that marijuana can make listening to music or watching a movie more viscerally exciting and captivating. It can also lend a visceral realness to our random trains of thought, including our dark and disturbing and depressing trains of thought. So I just want to clarify that point about marijuana a little bit. As I’ve often seen people express skepticism about marijuana’s role in mental illness, there’s a lot to talk about there.
Okay. Back to the talk.
Zach: So for me, the idea that there are psychological causes for madness is pretty easy to understand, because I went through some pretty painful mental experiences when I was young in college. It involved me feeling like I was on the verge of madness. I dropped out of college mid-year due to no longer being able to function. So I can relate to much of the things you write about in Madness Explained in a pretty visceral way, because it’s easy for me to remember how easy it is to become distanced from reality, especially when one is socially isolated and suffering. But I think for a lot of people that’s hard to understand just due to most of us taking our so-called normal minds for granted. So when we’re feeling good and feeling like so-called normal people, we have all sorts of healthy narratives going on in the background, like “I’m an independent agent interacting with other independent entities, and I’m able to enjoy these interactions I have with these other people. I have various goals that I can work towards that will increase my happiness.” These kinds of things.
And I think we tend to take for granted those kinds of really complex forms of narratives and modeling and modeling of self and modeling of other people. And as someone who went through basically what seems to me like, it was almost like a stripping away of all those social narratives and so-called normal narratives, and just being left with this real existential terror and shock at the weirdness of life. So I can see the things you write about in your book; I can relate to them and see how there are all these layers of meaning and narratives that make someone normal to other people and seeing those layers of meaning and narratives as just tremendously complex. And I’m curious if you see one of the challenges we face in trying to understand psychosis and madness is just that there are these things that we take for granted about normal life that are much more complex than they seem to be.
Richard Bentall: Yeah. So, I mean, I can’t remember who said it, but somebody said the thing about Freud was that he recognized that nearly everybody’s mad and they’re more aware of another; that’s a bastardization of Freud, I guess. But my point is that actually I think you make a very important point, which is that normal mental life is pretty weird and we underestimate its weirdness a lot of the time. And that comes out in all sorts of different ways. So one of the things for which it comes out with is that people who are going through a psychotic episode, they often feel very alone. They feel alone because they think they’re completely different than everybody else. And they think that nobody else will understand how they’re feeling, and they find it very difficult to express how they’re feeling or what they’re experiencing.
And that’s a terrifying situation to be in. You feel that your own mind is slipping away, but you are alone. Nobody can possibly help you because nobody can understand. But actually, if we look at epidemiological evidence, one of the things we find is that first of all, that these experiences are much more common than people used to think. So for example, it’s been estimated that, I mean, it’s crudely that roughly about 10% of the population at some point in their lives experiences hearing voices in somewhere some way or another. And actually there are quite a few people who had that experience who are living perfectly normal lives perfectly successful lives in the population without receiving or seeking psychiatric health. That was a great insight of Dutch psychiatrists, Marius Romme and I’m sure you’ve heard of. But Romme even went as far as to the MEA formed a club for a society for people hear voices, which was initially called resonance in Holland, and which supported the international hearing voices movement which has been a great force for good, I think, and maybe I can relate an anecdote, which I actually mentioned in my book about that movement because Marius invited me to give a talk to a conference of people who hear voices.
And this is back in the 1990s, and this seemed to be like a pretty strange thing to be doing because I was used to talking to mental health professionals, but not talking to a conference for people who hear voices. So I was a bit anxious about how it was going to go. And as just before I walked into the lecture theater, Marius said to me probably one of the most important things which anybody’s ever said to me, which was he said, “Richard, I really like your research on hallucinations, but the trouble is you do want to cure people who hear voices, don’t you? I want to liberate them. I think they’re like homosexuals in the 1950s. They need liberating, not curing.” And that’s a very powerful thought, I think. But going back to the weirdness of ordinary life issue, it’s certainly true that a lot more people hear voices than most people imagine.
But it’s also true that there are lots of, if we look at beliefs, for example, strange beliefs that there are a lot of people have straight beliefs as well. Now that sometimes it’s quite difficult to tell the difference between what’s a delusional belief and which is how a psychiatrist would define this abnormal belief that the person with psychosis might have. It’s difficult to tell the difference between what’s a delusional belief and what’s a non delusional belief, particularly in an era when there’s, for example, a lot of conspiracy theories going around on the internet. So this has become, that particular question is a preoccupation of mine. And I’ve began to do research specifically comparing the beliefs of the so-called delusional beliefs of psychiatric patients with, for example, very strongly held political beliefs or religious beliefs. One problem in that area, in terms of the way that other people approached it in the past is that people just take mundane beliefs for granted. So, for example, there’s a whole program of research on delusions about the phenomenology of delusions. Phenomenology is basically the experience of having these types of beliefs. Yeah. And phenomenologically inspired researchers spend a lot of time interrogating small numbers of patients about their experiences related to say their paranoid beliefs. And the bottom line is that what they usually end up saying is, behind these beliefs, there is some altered sense of self in the world. So it said, for example, that people who that paranoia is often preceded by a period, which in German is described as [foreign speech], which is this sort of sense that there is something in the offing, something’s about to happen, there’s something not quite right. And that precedes the onset of the paranoid delusion. But actually, if you look at narratives of people who’ve had religious conversion experiences, you find very much the same thing. But that’s been ignored by researchers because they’ve just taken mundane beliefs for granted. Actually a lot of stuff which goes on in the so-called healthy minds, it’s pretty weird.
Zach: Yeah. And the thing I was trying to get at, which I might not have explained, well, it’s something I often think about when I was trying to make sense of my own mental struggles as a young man, the thing I return to often is the idea that there’s just so much bandwidth and complex modeling processing power that’s required to be a so-called normal person. You have to have these models of other people. You have to have this model of your own self. You have to have this model for how yourself is perceived by the others around you. You have to keep all the social rules that dictate what is acceptable normal behavior in mind when you interact with others. And it just seems to me like such a large amount of bandwidth and processing.
And then when you’re in the world of other people if you start to feel bad, you start to feel anxious, depressed, you can start to have all these balls that we usually juggle interacting with other people or thinking about ourselves as social creatures. It becomes harder to keep all those balls in the air. And so you have this cascading effect where our narratives about ourself and our place in the world become more strange and less functional, less realistic, and we can start to have these weird ideas just based on this cascading effect of us not being able to keep all these ideas of others and self in mind at the same time. And I’m curious if is that something, as someone who’s an amateur, I don’t really have a sense of if that makes sense or if people have talked about that in the mental health literature.
Richard Bentall: Yeah. So there’s quite a big American particularly psychological literature on intentional limitations and their role in psychosis. It’s certainly true that people who suffer from psychotic disorders do have reduced attention span. In fact, Kraepelin recognized that in the 1890s. So in his accounts, his descriptions of people with what he called dementia praecox, what was later renamed as schizophrenia. And it’s certainly true that in ordinary everyday life, we have to juggle all these things as you’ve described. So I’m trying to think of somebody who’s formulated it in quite the same way as you have and I’m not quite sort of, nothing’s coming to mind immediately, but what you’ve described doesn’t sound to me particularly implausible actually as an account that if you imagine that if your capacity or working memory capacity, your intentional capacity is impaired, then ordinary everyday situations are going to be much more problematic and stressful.
And I suppose one of the things related to that is that a lot of the social psychological processes which underlie everyday social life are normally automatic. So a good example would be what developmental psychologists misleadingly call theory of mind. Theory of mind is the ability to understand or be able to guess what other people are thinking. It’s called theory of mind because a better term will be mentalizing, actually, because it’s an ability, it’s called theory of mind because the concept was first brought to attention by celebrated paper by David Premack about chimpanzees actually won’t, the title of paper was, does a chimpanzee have a theory of Mind? So we know that certain people find mentalizing or understanding other people’s mental states much more difficult than others, notably people with autistic disorders. And indeed there are some people who argue that that is the central problem in autism, although that’s disputed about whether that is the case. And it’s certainly true, and I’ve done studies myself going back a while now, it showed that when people are acutely ill, that their theory of mind skills, their ability to think about other people’s mental states are impaired. So there is certainly some evidence which fits with our idea, which is, if our processing capacity is handicapped in some way, then it’s going to make social situations much more tricky and actually more frightening.
Zach: The thing that strikes me there is when I was going through my mental struggles, I had this very visceral feeling. When I felt like I was losing my mind, I felt like I was a million miles away from basically other people. I felt like I was almost on like metaphorically another planet and it was losing these, it strikes me that losing these narratives about if we feel that we’re so isolated in our own minds and we, we basically are going into our own minds then we lose these narratives about it even being important to pay attention to the things that other people think are important. So I’m reminded of you open madness explain with your work with the mentally ill women at the mental hospital who you were trying to walk them through these attention paying exercises. But it’s like if they don’t even have the narrative that such things are important, they’re not going to. Their lack of paying attention.
Richard Bentall: What you’re referring to is my first ever work with people with psychosis when I was still a student and was, what can I say? I’m quite embarrassed about it, really in some ways compared to,
Zach: But you were young.
Richard Bentall: Certainly in terms of my understanding of psychosis at the time was very minimal, but so was everybody else’s, I think. Yeah. Now we just had this idea we could actually teach people to improve their attentional skills by getting them to, actually, the ideas came from, it’s linked to this in the speech idea. The idea was that if you get people to talk to themselves while they’re doing whatever they’re doing but to literally instruct themselves, it will focus our attention. We got a change in people’s performance on simple IQ type tests but I’m sure that improvement lasted for about five minutes.
Zach: Yeah. I think it gets back to that idea of the kinds of tests, it’s like the early testing of mentally ill people, having them try to recite things. It’s like, well, if their narratives are not in their world that they’re living in, such things do not matter at all. Whereas we’re in the world of living with other people, and so we care what others think where they’re just not in that frame of reference of the normal test. Just there’s only so much you can learn if their narratives are not matching ours.
Richard Bentall: So I guess one thing which is just reacting to what you’re saying is that actually that this ties in with something which I’m preoccupied with at the moment. I was mentioning earlier on that I’m interested in what makes a belief a delusion as opposed to, for example, if you take something like QAnon, like expressive theory which is associated with the MAGA movement in the United States. I mean, on the surface it seems just as crazy. So I can use that termas anything which you’ll see in the psychiatric hospital. I mean, some of these people believe that there is some vast conspiracy led by the Democrats to sexually abused children worldwide and even drain hormones for their bodies. So I’d say it’s pretty crazy. And yet it’s not usually considered to be a delusion.
One of the things which makes delusions different than other types of beliefs is that they’re generally not shared. So delusion there’s only only one person who believes in delusion, a particular patient. Whereas things like QAnon, they’re shared by lots of different people. And that points to something which is quite important about belief formation in general life, which is most of us get our beliefs in interaction with other people. So belief formation is a social process. You discuss what you think with other people, you negotiate a shared understanding of what’s really going on and beliefs get passed from one person to another. There’s some people like that process to the process of viral infection, but none of that seems to be happening in the case of delusions. And I’ve come to think that in a way psychologists have missed the point a bit about delusions because what we’ve done is we’ve spent the last 20 or 30 years trying to look at reasoning in people with, say, paranoid beliefs.
And there’s not a huge amount of literature which seems to show, well, if you test people on this psychological task, they seem to be reasoning a little bit different than everybody else. It’s usually nothing particularly dramatic. And I think I might be missing the point, it’s more to do with the way that police are constructed in collaboration with other people, which is seems to be the problem in delusions. And that to me would say that even though I think that say QAnon is a pretty crazy theory, I wouldn’t really say it’s a delusional theory in a way, the fact that it’s shared, it’s a narrative developed by lots of people interacting with each other is makes it precisely not a delusional belief. Doesn’t mean it’s a correct belief, by the way.
Zach: Yeah. I think the I mean, and then as society’s become more polarized and more angry, it becomes easier to have these high animosity, strange beliefs that are paranoid about the other side doing things. That those things become more common. So I definitely, I believe you’re working on a book now about those topics and I can see the map over for all of it. And one thing that strikes me too, I mean, one of the takeaways from my own mental struggles was being very skeptical when I thought that I’m now very skeptical when I think I have some sort of truth that other people don’t have which is one of the things that was one of the things that led me down a dark path was thinking like, oh and some of it had aspects of positive things too or feeling positive where I thought I was reaching some form of enlightenment, I was reading books about Buddhist schools of thought and so at the same time as I was becoming distanced in a socially painful way, I was also having these periods of feeling like I was a genius and things like that.
So I think it maps over to some of the experiences so-called normal people can have, where we feel that we’ve reached these realizations about narratives that explain the world or explain our place in it and it’s good to be skeptical of those things because reality is largely defined by our interactions with other people so-called reality. So there can be negative sides to delving off into these other worlds, whether it’s like QAnon or what other unusual or unlikely worldviews. Would you agree that a big part of mental illness and mental struggles maybe in general is when we go off in our own heads a bit and reach these narratives that are not agreed on by other people? Would you largely say that’s it?
Richard Bentall: Yeah, no, that’s in a sense my point really, I suppose that’s normally the narratives, we have to use your terminology, they’re constrained by our social relations. They’re checked by other people formally or informally. Your friend says, “Nah, I don’t think that’s what’s going on.” Or they say”Have you thought about this? That might be.” So on. Those kind of things. And in a coalition, you develop your beliefs in a coalition. But if you’re isolated, if you’re frightened of other people, which of course will increase your isolation, then you can’t form as coalitions. So the whatever’s going on in your head is unconstrained. It isn’t limited, it isn’t moderated by anybody else. We all have, I think, pretty crazy ideas which go through our heads. I know I do, every so often, but what most of us can do is either it gets dismissed for us by somebody else who we discuss it with, or we dismiss it ourselves because we go, no, I think that’s a crazy idea.
I’ll give you an example. I use this example when I’m talking to students. It always creates a bit of amusement, an almost everyday occurrence if you are a academic researcher which is a good model of paranoia. So if you’re researcher, what happens is you write a scientific paper and it takes you ages to do it. You finesse it as well as you can. You stick it in the poor submission portal as it is these days. We used to post them back in the old days. But you put it in the submission portal of whatever journal you are hoping will accept it. And usually you will start out by aiming high, you’ll find some journal, we’ll think of some journal which has got a really high, what we call citation impact, which is otherwise it’s read by a lot of people but they’re difficult to get into because they’ve got a vast number of people sending papers done.
So I send it there, and then you wait and you wait and you wait and weeks go by. And then finally you get this email back and the email says something like, “Dear Professor Bentall, thank you for submitting your paper on paranoia in UK academic staff to the journal of very excellent psychopathology research. At this journal, we have considered your submission very carefully and asked free expert reviewers to review it. The reviewers all identify strengths in your work.” And you’re reading this thing and you’re going, no, come on, come on. What’s the bottom line? And then you get after a while. So sometimes it goes, “But unfortunately, some important weaknesses were also identified, which are,” And then they go, “We can only accept 5% of papers, which is submitted to our journal. So unfortunately we must decline your submission.”
And what’s the first thing which happens to an academic in that situation? Well, I’m pretty sure I’m not alone in feeling pretty paranoid. So what happens is, very often you go kind like, “Who else is working in this area? Who are those three referees? Let me look what they’ve read. Oh, those bastards.” And you get very angry. You could easily develop a paranoid worldview that all the other scientists are against it and so on. And so actually some people do develop that paranoid worldview, but most of us, what happens is we get very upset and then we go and have a cup of tea in Britain, a cup of tea, I don’t know what it would be in North America, probably coffee. But you go and you sit back and you relax a bit and you think, that journal is a pretty hard journal to get into.
Also, what the referees said wasn’t completely wrong. There were some things I could do to improve the research or maybe the way I reported it and so on. And you slowly taught yourself round to thinking, now this is just what happens. It’s just one of those things I need to see if I can learn from the referees reports to improve the paper, but I’ll send it to another journal and get in somewhere. So you talk yourself out of your paranoid episode. And whenever I talk about this to, use that example with either students or in academic conferences, there’s always smiles around the room because everybody recognizes that feeling, the feeling of paranoia when you have a paper rejected. The problem with, I think people are very isolated or with that cognition is compromised for whatever reason, maybe because they’re emotionally distressed and their working memories is limited or whatever, but it’s much more difficult to talk yourself out of a strange belief like that. So, whereas your average university professor can go, hold it, I’m being a bit paranoid. No, I’d be a bit more realistic about this. I need to calm down. I have my cup of tea. Maybe it’s simply the case that a lot of people with psychosis can’t do that.
Zach: Do you want to talk a little bit about what you’re working on right now with your book?
Richard Bentall: I’m still involved in clinical trials and the one thing we haven’t talked about is the role of trauma in psychosis. So one of the things which has emerged in the last 10, 15 years, I think, is that very often people with psychosis have some significant social trauma in the past. Going back to what I said about parents, of course it’s very important to recognize it’s not always the parents who are responsible for those traumas, but it appears that we’ve now got quite a lot of evidence that that traumatic factors are one of the causal factors in what type of causal factor in psychosis, for sure. So I’m involved in clinical trials to develop treatments which are targeting particularly trauma related mechanisms. But apart from that, yeah, no, I’m writing a book. It’s been going on. I’m not going to say how long I’ve been writing it for because it’s too embarrassing.
But a long time ago I came to the conclusion that I didn’t really understand what a delusion was. I’d been doing research on delusions for 20 years. I thought I’d discovered some vaguely useful things, but I thought that the whole area was a bit stuck. That we’re doing, seeing a lot of studies come out where people are doing the same old thing more or less or another with slight variations. And it suddenly struck me that part of the problem was we didn’t really know what a belief is. Which seems a bit strange because beliefs are central concept in all of the social sciences. Arguably you could say that it’s a focus on belief, which is what distinguishes the social from the natural sciences. Sociologists talk about beliefs, anthropologists talk about beliefs, historians talk about beliefs. Psychologists talk about beliefs, but there’s no coherent understanding of what beliefs are.
And it seemed to me that if we could have a better understanding of how beliefs are generated and what they are involved in general, that would inform our understanding delusions. So I’ve been involved in this task of, I basically managed to get a contract quite from a very well known public, well from Penguin, where I said I don’t know what a delusion is, but if you give me a contract, I’ll write a book. And by the time I finished writing the book, I’ll know. And amazingly they did because they were very happy with previous books I published and I had no idea how difficult that task would turn out to be. So I’m currently writing quite a, I’m just polishing off a lot of sections and about political beliefs, for example, and it turns out there’s a lot we can learn about belief systems in general by looking at political beliefs.
And those have some applications to thinking about the beliefs of psychiatric patients. The problem with it’s endlessly fascinating so I found myself today trying to improve a section I’d already written about the left right spectrum where fascist ideology fitted into it and I could end up.
Zach: Going deep.
Richard Bentall: Could end up going down a day. That’s a rabbit hole which I could have disappeared in for three weeks so I won’t. I written a huge long section about Ezra Pound, the American modernist poet who, I don’t know if you’ve heard about the story of Ezra Pound but.
Zach: Not sure.
Richard Bentall: Ezra Pound, put it briefly Ezra Pound modernist poet, fascist and psychotic question mark, because he was somebody who had quite appalling political views really. He was a sport of fascism. He was viral anti semite. He was an American citizen who did radio broadcast on behalf of the Italian government during the Second World War. And at the end of the second World War was arrested by the FBI and indicted for treason, potentially faced the death penalty, at which point it was decided that he was psychotic and he spent the next 12 years in the psychiatric hospital. Looking into the life of Ezra Pound, it really is difficult to, it’s a fantastic story about how difficult it’s to tell what is just an awful political belief or what is a delusion. Just say, I’m finding it’s enormously enjoyable, but I’m spending far much, it’s taking far too long.
Zach: Quick question, if you do have time for them. One thing I’ve been curious about is in mental illness, do you write about at all the idea that sometimes when someone’s not feeling well, they can have a hard time telling a belief from a passing thought? And so like a passing thought can in the way that we shrug it off and say, that was a weird passing thought we had. They might dwell on it and start to think that was it.
Richard Bentall: Yeah. So that is one of the things I haven’t actually written anything about that in the book yet, but I will be covering that. But some interesting ideas from psychotherapists around that, actually, I don’t know if you’ve heard of acceptance and commitment theory?
Zach: No.
Richard Bentall: Therapy, sorry. It’s sort of brand of CBT. I mean, therapists are always trying to invent new brands of therapy which I’m not sure is always a good thing. But anyway, but there’s some interesting ideas in ACT particularly ACT therapists put a lot of emphasis on the idea that people find it very difficult to distinguish their thoughts from themselves. So you have, all of us got these thoughts going through our heads of feelings and so on, and we can become so preoccupied with them that we think they’re reality basically.
And so what ACT therapists try and do is do, one of the things they do is they try and help people to see, to distance from her thoughts with the idea that once they’ve done that, then they can actually pursue aspects of a life which are actually more important and more valuable to them. So, an ACT therapist use a lot of metaphors. So, and I did do a little bit of ACT therapy before I stopped seeing patients. It was a very new psychotherapy then but I found it quite powerful actually. So one of the metaphors will be to ask, say to the patient, well imagine your mind is a chess board and there’s black squares and white squares. But unlike a traditional chess board, it goes on forever. It stretches forever in each direction.
And there are black pieces and white pieces trying to clubber each other. The bad thoughts and the good thoughts trying to clubber each other. Unfortunately if although the white thoughts, the white pieces can win for a while, they’ll always be some more black pieces. And then the therapist says, so where do you think you are in this picture? And I can remember a patient saying to me, well, oh, I think I’m a little gray piece somewhere in the middle. And the answer is no, you’re not. You’re the chess board. The board. And that’s the point that the thoughts are not you you’re just the space where they happen.
Zach: You wrote about this related to your, something you mentioned in madness explaining which was the studies that showed that people that were more intolerant or that the strange actions of their mind bothered them more, were more likely to have issues. Getting used to the idea that our mind can do strange things and that’s not necessarily a bad thing. And that’s even normal.
Richard Bentall: Yeah. So, there’s a whole psychological literature on what’s called metacognitive beliefs, which is your beliefs about your beliefs. And if you have a set of standards for your own mind, if I can put it that way, which your own mind can’t meet, then you’re going to become highly distressed. You’re going to think you’re weird, that you’re different than everybody else and your mind is completely out of control but if you accept that your mind just makes mistakes, does weird things every so often, then that pathway doesn’t have to be followed if it speaks to me.
Zach Elwood: That was the psychologist Richard Bentall, author of Madness Explained and many other respected books on psychology. If you want to know more about him, you can check out the entry for this episode on my site behavior-podcast.com. I’ll put some links to his work there, and some other resources related to things we talked about.
This has been the People Who Read People podcast with me, Zach Elwood. If you like this podcast, please do me a favor and recommend it to your friends and family. Helping me gain listeners is the best way you can encourage me to work more on this podcast.
And just a reminder that I have several previous episodes that deal with mental illness and mental health.
Thanks for listening.