The Titeca psychiatric hospital in Brussels, Belgium, 14 April 2020. Photo by Francois Lenoir/Reuters


The helpful delusion

Evidence is growing that mental illness is more than dysfunction, with enormous implications for treatment

by Justin Garson + BIO

The Titeca psychiatric hospital in Brussels, Belgium, 14 April 2020. Photo by Francois Lenoir/Reuters

Most people thought my dad lived alone. He didn’t. He lived with God and the French actress Catherine Deneuve. They were outside of him but somehow projected their voices into his mind.

Throughout my teens and 20s, the four of us would have conversations over coffee and cigarettes. Catherine was always kind to me. One day before a job interview, she said I looked quite handsome and my prospects were good. She never meant to harm my dad, but she did get him into trouble once in a while.

One night, around two in the morning, she played a joke on him. She said she’d flown from Paris to Washington, DC in the flesh, and was hiding in his apartment building. She was tired of projecting her voice into his head, she explained, and wanted to see him in person. Upon hearing this, he jumped out of bed naked and ran through the narrow hallways of his apartment complex in Dupont Circle screaming: ‘Catherine! Catherine! Where are you?’ She would taunt: ‘I’m just around the corner!’ He must have seemed like a real maniac. That night ended with another hospitalisation. These stays always followed the same script. First, the doctors would give him drugs that stopped him from hearing God and Catherine. Then they would watch him for a few days. Then they would reprimand him for getting off the antipsychotic medications, and threaten routine blood tests to ensure his compliance. Then they’d let him go. To them, ‘bipolar disorder’, ‘schizoaffective disorder’ and ‘schizophrenia’ were names of diseases, akin to ‘cancer’, ‘diabetes’ or ‘fibromyalgia’. They weren’t portals into strange, exhilarating and sometimes frightening new worlds.

In 1991, shortly after starting college, I visited my dad in his studio apartment and then had a revelation that continues to shape my academic career today. Sitting on his bed and holding a cigarette thoughtfully, he said: ‘Justin, I know God and Catherine aren’t real. I know they’re not really talking to me. I just have a strong imagination. But I don’t know what I would do without them. I have nothing. I don’t have family nearby. I don’t have a job. I don’t have a girlfriend. I don’t have money other than the pension. They’re all that keep me company.’

It dawned on me then that God and Catherine might not have been byproducts of a diseased brain. They may have had a function, or purpose. I began to wonder if the psychiatrists who looked after my dad were too quick to slap the ‘disorder’ label on his experiences. What if some of the things people describe as mental disorders are purposeful, not pathological?

I didn’t think much more about these questions until 10 years later when, as a grad student in philosophy, I stumbled upon the book Why We Get Sick: The New Science of Darwinian Medicine (1994) by Randolph Nesse, a physician, and George C Williams, an evolutionary biologist. They argued that real progress in medicine won’t happen until we look at health and disease in terms of the big picture of evolution. When we do that, conditions that we’ve long considered to be diseases can turn out to be adaptations. That is, we can see them as shaped by natural selection because of an advantage they gave to our ancestors. They’re functional, not dysfunctional.

Think about fever. From ancient Greek times through to the Middle Ages, many doctors ‘knew’ fever was a disease – a ‘heat contrary to nature’ as Galen put it. The only question was how to destroy it before it destroys you. But then in the 18th century, the German chemist Georg Stahl advanced a brilliant insight that is universally accepted today. Rather than being a disease, what if fever is actually the body’s healing response to infection?

Seeing fever as functional, not dysfunctional, didn’t mean you stopped treating it. Rather, it transformed the character of treatment. Fever was no longer the thing you’re trying to attack, to stifle, to pummel with medications. Instead, you recognise that the fever has a role to play in the healing process. The purpose of medicine is to comfort the patient and curb fever’s excessive manifestations.

Depression can be the brain’s evolved signal that something in a person’s life needs to change

In their book, Nesse and Williams advanced the hypothesis that some mental disorders, such as depression, also have an evolved function, just as fever evolved to fight infection, or calluses evolved to protect the skin from friction. But what could possibly be the evolved function of depression? From extremely low moods, to lack of sleep, to chronic feelings of worthlessness or guilt, all the way to thoughts of, or attempts at, suicide, depression seems to fall clearly on the dysfunction side of the fence.

In later work, Nesse argued that depression is sometimes the brain’s evolved signal that something in a person’s life needs to change, such as a harmful relationship, an unrealistic career plan or a goal that needs to be re-evaluated. What that means in practice is that it’s not always best to bombard depression with medication. Sometimes, it’s better to figure out what depression is trying to say. The theory that depression is an evolved signal doesn’t ignore the fact that depression often has a tragic outcome. Nesse and Williams’s core point was that we can no longer take the dysfunction paradigm as the silent default when treating depression.

I wondered if anyone else grasped how subversive this book was to contemporary psychiatry’s disease mentality. I also wondered if anyone else in history had advocated a similar point of view. Of course, before Charles Darwin, doctors wouldn’t have had the language and concepts of evolutionary biology to express their ideas. Instead of saying that depression is an evolved adaptation, they might have expressed themselves in other ways.

The first name that came to my mind was Sigmund Freud. To me, his most important idea wasn’t the Oedipus complex (which nobody believes in anyway), infant sexuality, or the death drive. Rather, it was the idea, which drove his life’s work, that each form of what he called ‘madness’ has a special function, just like fever or calluses.

Specifically, he saw that its goal is to help us satisfy unconscious wishes – but in a disguised form. According to him, a young woman’s compulsive need to arrange and rearrange the pillows on her bed lets her symbolically fulfil her unconscious wish to sleep with her father, but in such a way that she never becomes aware of its real meaning. Freud was adamant that, often enough, the conditions we label ‘pathologies’ are actually the expression of an unconscious goal. Early psychoanalysts such as Frieda Fromm-Reichmann and Harry Stack Sullivan attempted to apply this perspective to treating schizophrenia.

Don’t get me wrong. Freud was mistaken about a lot of things (including about the pillow-arranging woman who likely had no such unconscious wishes, but was probably using compulsions to try to contain her anxiety). My point is that Freud insisted that mental disorders as diverse as hysteria, compulsive behaviour and delusions were purposeful, not pathological.

I kept digging through the annals of psychiatry, rifling through old books and articles to find others who’d had a similar insight. Take Philippe Pinel, the head of the Bicêtre and Salpêtrière mental asylums in Paris during the French Revolution. Historians remember Pinel as someone who helped introduce the ‘moral treatment of the insane’ to France, but they often overlook his other radical ideas, such as that some intense episodes of manic psychosis, which he called accès de Manie, had a healing power – after such episodes, he observed, chronic patients were often ready to be discharged.

Some delusions are actually coping mechanisms that help to shield the mind from traumatic experiences

The conclusion Pinel drew? These attacks had a ‘salutary’ and favourable impact. He even had the audacity to compare himself with Stahl. These psychotic episodes are like fever: it’s not the thing that makes you sick, but the thing that stops you from getting sicker. Pinel used sarcasm and humour to ridicule his medical colleagues who tried to stifle psychotic episodes with drugs, bleeding, purging and vomiting: ‘I ask now if all physicians who seek to cure similar attacks, do not deserve to be put in the place of the madman himself?’

Another theorist I encountered was the German Johann Christian August Heinroth, who worked around the same time as Pinel. He was the first chair of psychiatry in Europe. In his 1818 textbook, he argued that some delusions are actually coping mechanisms that help to shield the mind from painful or traumatic experiences. In the best of cases, he thought, the delusions would abate of their own after achieving their healing end. That same year, the pessimistic philosopher Arthur Schopenhauer, in his magnum opus The World as Will and Representation (1818), made a similar point.

My explorations led me further back, to 17th- and 18th-century thinkers such as Robert Burton and George Cheyne. Steeped in a religious worldview, they saw madness and melancholy as God’s response to our sinful choices. But God’s ultimate goal wasn’t punishment: it was reformation. Cheyne, for example, thought that excessive drinking leads to melancholy – but melancholy is how God gets us to stop drinking. Similar to Nesse, Burton thought that depression was a ‘designed signal’ that something in a person’s life needs to change. These thinkers form a chain that stretches back to the time of Hippocrates.

As I did this research, a vision began to unfold before me. What if you could tell the story of psychiatry, from the ancient Greek doctors to today’s geneticists and neuroscientists, in terms of a profound schism? This schism isn’t the one we often read about, between proponents of a more psychoanalytic ‘mind’ versus more biological ‘brain’ point of view. It’s a clash between those who see purpose in madness – I call it ‘madness-as-strategy’ – and others who see only pathology and disease, or ‘madness-as-dysfunction’. And what if this historic battle is coming to a head today?

Colleagues have been sceptical about the way I’ve assembled such diverse figures under the single madness-as-strategy category. It’s true that when you zoom into the details of their theories and worldviews, there’s tremendous divergence, even contradiction. But I see the crucial common thread that unites them as more important. By recognising that something always put in the ‘dysfunction’ category actually belongs in the ‘function’ category, Burton, Stahl, Pinel, Heinroth, Freud and Nesse all made a gestalt switch of momentous proportions – unlocking fundamentally new forms of research, classification and treatment. And perhaps now the tide is finally turning in favour of their side of the debate.

In the nearly 30 years since the publication of Why We Get Sick, the field of Darwinian medicine has exploded. Today, there are numerous textbooks, university courses and scholarly articles on the topic. Evolutionary psychiatry in particular is witnessing a flurry of interest. In the past eight years, three textbooks on the subject have been published, each drawing on hundreds of scholarly articles. It feels to me as if we’re on the verge of a deep-rooted paradigm shift in psychiatry.

Evolutionary psychiatry doesn’t insist that all mental disorders have evolved functions. For instance, Lewy body dementia, which affected the actor Robin Williams, can lead to depression and personality change, which can be traced to a build-up of misfolded proteins in the brain. But the evolutionary approach has revealed at least three ways that various mental health ‘disorders’ might actually be functional: some represent evolved responses to current crises; others, evolved responses to past crises; and still others, evolved cognitive styles. The real value of thinking of mental illness in terms of function isn’t to destroy the dysfunction paradigm, but to show why it can no longer serve as the default starting point for all psychiatric thinking and practice.

Depression is probably the best candidate for the first type of function – an adaptation to a current crisis; nature’s attempt to show us that something in our lives isn’t working out, and to motivate us to make the right changes. When the issue that depression is trying to shed light on isn’t obvious to us, therapy can be extremely valuable to help us see where the problem lies. Sometimes, we might be so sunk into our depression that we need medication to lift us out of it for long enough to be able to address the root problem. There’s no contradiction between seeing depression as functional and seeing a role for medication.

Emerging evidence suggests that dyslexia is actually a distinct cognitive style in its own right

Other mental disorders aren’t evolved responses to a current problem, but to a past problem. Borderline personality disorder (BPD) is a plausible example. BPD is associated with a cluster of personality traits including mistrust of others, hypervigilance to rejection, fragile interpersonal relationships and impulsiveness.

Although some have described BPD as involving a brain dysfunction, such as a frontal lobe deficit, a widely accepted viewpoint is that BPD traits are coherent responses to adverse childhood experiences, such as abuse, neglect and trauma. In fact, 80 per cent of people diagnosed with BPD report such adverse experiences. The evolutionary psychiatrist Martin Brüne recently sought to make sense of BPD traits as an evolved adaptation to such adverse experiences, or as a kind of exaggerated, maladaptive version of such an adaptation.

Of course, to say that BPD traits are an adaptive response to an early, adverse experience doesn’t mean those traits continue to be advantageous through life. In fact, they can stand in the way of developing long-lasting and meaningful relationships. The point is that the evolutionary perspective can inform approaches to treatment. A goal of therapy could be to help people see why they adopted those strategies early in life, and why those strategies might be limiting their possibilities today.

A third trend in evolutionary psychiatry is to see certain disorders, such as dyslexia, as evolved cognitive styles, rather than dysfunctions. The conventional biomedical perspective sees dyslexia as a disorder of reading and writing that stems from a brain dysfunction that hurts our ability to match sounds and shapes. However, emerging evidence from archaeology, neuroscience and cognitive psychology suggests that dyslexia is actually a distinct cognitive style in its own right, with its own strengths and benefits.

Consistent with the evolutionary perspective, people with dyslexia often have a ‘big picture’ grasp of their environment. For example, they’re quicker to notice when a work of art represents an impossible figure, such as M C Escher’s Waterfall (1961). They also excel at ‘divergent thinking’, the ability to come up with multiple solutions to the same problem. This perhaps explains why, according to one study, roughly one third of American entrepreneurs have dyslexia. Early communities may have found people with dyslexia to be a real asset, as they needed to rely on big-picture thinking and problem-solving abilities in order to survive and thrive. If the evolutionary psychiatrists are right, we need to change our educational systems to allow people with dyslexia to exercise their cognitive gifts, rather than stifle them.

Sceptics might wonder if there are limits to the evolutionary approach to mental health. For instance, how might it help us think about psychotic delusions? Are they not a perfect example of something ‘going wrong’ in the mind? It’s hard to see anything positive or functional in having the conviction that a celebrity is in love with you, that you’ve been charged with a secretive mission of geopolitical significance, or that you’re the second coming of Christ. Surely, delusions are severely dysfunctional?

In fact, groundbreaking research is starting to suggest a more expansive picture of delusions that’s also in keeping with evolutionary psychiatry. For instance, a survey of the content of delusions, led by the psychiatrist and philosopher Rosa Ritunnano found that there’s a category of delusions that can be best understood as the mind’s attempt to find meaning in the face of a crisis, such as a relationship breakup or financial worries. Ritunnano’s theoretical convictions are mirrored in her clinical work, where she helps clients explore how their delusions might guide them through the challenges of life.

Similarly, the clinical psychologist Louise Isham and her colleagues recently studied grandiose delusions – of the kind experienced by the mathematician John Nash, who believed he was conducting secret government work, as depicted in the movie A Beautiful Mind (2001) – and found that the greater the grandiosity of delusional beliefs, the more they tended to give people a sense of meaning in life. Isham suggests that it’s precisely this sense of meaning that might explain why people can hold on to these delusions for so long.

He became convinced that the FBI had wiretapped his phone, which was not entirely improbable

Reading about the work of Ritunnano, Isham and others, I couldn’t help thinking back to that conversation with my dad. I wondered if these contemporary researchers had pinpointed, precisely, what my dad’s doctors were simply unable to see. Was it possible that his voices, and the strange beliefs he formed about them – that a celebrity was in love with him, that God had given him a world-changing mission – infused his life with a powerful sense of purpose?

It wouldn’t be a stretch. My dad was an extremely ambitious person. The son of Lithuanian Jewish immigrants, he completed a Master’s thesis in English, and then received his law degree from Harvard Law School. In 1967, he co-authored an article that helped to open US-China trade relations, and went on to become an international tax lawyer for the US government, working under Richard Nixon. During this time, he became convinced that the FBI had wiretapped his phone, which was not entirely improbable. The pressure he experienced culminated in a series of psychotic episodes. Although he was able to continue in his position for another decade, similar episodes in the mid-1980s made it impossible for him to continue working, hence the flimsy government pension and the studio apartment. From the perspective of his previous accomplishments, by the time of the chat I had with him in his apartment, he practically had ‘nothing’ – but for God and Catherine.

I must tread carefully here. To say that some delusions give us a sense of meaning in life is far from saying that the capacity for delusions evolved, by natural selection, for that very reason. By definition, natural selection selects traits only on the basis of whether they give us, or our close relations, a reproductive edge. While it’s possible to see delusions as psychologically useful in some ways, that doesn’t mean they’re biologically adaptive – though some cognitive neuroscientists have made that argument (they propose that delusions can help us make sense of unusual perceptual experiences, and thereby help us continue functioning in the world).

Even if the capacity for delusions didn’t evolve by natural selection, seeing their psychological benefits has an important treatment implication. It’s the same lesson that Stahl taught us regarding fever. Trying to attack the delusion head-on might do far more harm than good. Rather, you want to help the person find alternative, and less harmful, ways of achieving the same goal of having a meaningful life.

In fact, some support groups, such as the Hearing Voices Network and Open Minded Online aim to provide people with the tools they need to manage their voices more constructively, rather than seeing them as the symptom of a disease to be medicated. Newer approaches to healing, such as the Open Dialogue model, emphasise the role of family and extended support networks in helping people during psychotic episodes, and seek to minimise the need for hospitalisation and antipsychotic medications.

The implications of the madness-as-strategy perspective don’t stop with treatment. After talking with scientists like Ritunnano, I began to think about the messages often sent by the prevailing madness-as-dysfunction view to people who’ve been diagnosed with serious mental disorders. What if many of the dysfunction-based terms and phrases that are in common use, for instance among social workers and on educational YouTube videos – such as ‘chemical imbalance’, ‘brain circuit disorder’, ‘depression is like diabetes’ – end up harming the very people they’re meant to serve?

Unfortunately, contrary to the hopes of the National Alliance on Mental Illness and others who’ve described mental illnesses as diseases, recent research does not support the claim that madness-as-dysfunction explanations of mental illness reduce stigma. According to some studies, they actually increase it in some ways. That’s because biological explanations (such as the chemical imbalance view) encourage people to think of mental health problems as permanent, and that the person so affected might be dangerous and unpredictable, and that we should distance ourselves from them. It also leads service users to be more pessimistic about treatment outcomes.

In contrast, there’s preliminary new evidence that seeing depression as a functional signal that something in life isn’t working out might lead to better treatment outcomes and reduced stigma. One researcher who studies this is the clinical psychologist Hans Schroder. Several years ago, Schroder decided to introduce the evolutionary psychiatry account of depression to his patients. What if their depression is ‘trying to tell them something’? Afterwards, he noticed that things started to change. Some became more enthusiastic about therapy. Some felt, for the first time in their lives, a glimmer of hope. They stopped seeing their depression as an irreversible brain defect, and started seeing it as a coherent response to a crisis.

Our casual use of disease language isn’t just scientifically dubious. It may be immoral

In subsequent research, involving people with experience of depression watching videos that espoused either the chemical-imbalance view of depression or the depression-as-signal view, Schroder confirmed his earlier observations in the clinic. Patients who watched the ‘signal’ video scored significantly higher than the other group on three measures of wellbeing: they felt less helpless about their depression; they felt that their condition gave them more useful insights; and they felt less stigma about it.

To me, this shows the long-running schism in psychiatry between seeing mental problems as dysfunctional or functional is more than a long-running intellectual debate – it’s of profound ethical importance too. Our casual use of disease language isn’t just scientifically dubious. It may be immoral.

Looking back, I wonder what my dad would have thought about these contrasting paradigms and the rise of evolutionary psychiatry. Unfortunately, we never got to talk deeply about them. In the 1990s, my dad started having problems moving his limbs correctly. Movement disorders are a well-known side-effect of the antipsychotic drug he was on, chlorpromazine.

At first, he struggled with fine motor control. A simple attempt to tie his shoelaces, or feed a dollar into a vending machine, could release a frenzy of curses. Over time, his gross motor control started to suffer, too. He couldn’t move for long distances, like at an airport, without a wheelchair.

Eventually, his doctors switched him to one of the newer (‘second generation’) antipsychotic drugs, which are supposedly more benign. But, by then, it was too late to reverse the motor damage. The newer drug, clozapine, had its own nasty side effects, such as painful ankle swelling and severe constipation.

By the early 2000s, my dad’s motor problems affected his ability to swallow normally. His brain couldn’t control his epiglottis – the thin tissue that stops food and water from going into your lungs. This may have been what doctors now call antipsychotic-induced dysphagia. Drinking a glass of water could send him to the emergency room. After several bouts of pneumonia, he died in 2005, right about when I started my philosophy dissertation on the concept of mental disorder.

I sometimes wonder if my academic work would have changed anything for him. I imagine what might have happened if he’d known about organisations like the Hearing Voices Network, or the Open Dialogue model, and had a chance to learn about better ways of engaging with his voices. I think about what might have changed if he’d had a therapist who was willing to consider that his hallucinations and delusions had a hidden function, and crafted a gentler treatment plan for him. Sometimes I think I’m still trying to speak with him, screaming across the abyss, telling him nothing was wrong with his mind.