Virtual Realities: On Delusion, Shame, and Intersubjectivity

In our contribution, we note the remarkable nature of Dr. Michael Garrett’s (2020) case study of "Sean" and of the rich therapeutic relationship he so eloquently describes with his client.  We then discuss several overlapping topics: the question of diagnosis and functional considerations, the patient’s attitude toward his delusions, and certain issues pertaining to the therapeutic relationship.  Regarding diagnosis: we ask about the extent to which the patient "Sean" might or might not qualify as a case of schizophrenia. It is not clear from the report that Sean demonstrates the widespread disturbances of perception, cognition, and affect that would be expected in prototypical cases of schizophrenia. His psychopathology seems largely bound up with his delusions or delusional system, and these latter do not seem distinctively "bizarre." We suggest that "Sean" might better be viewed as a case of delusional disorder (while recognizing the vagueness of the boundaries between these and other conditions). We examine Sean’s attitude toward his delusions in some detail, asking whether this seems in keeping with what is assumed by the standard poor-reality-testing formula that is adopted in mainstream psychiatry, psychoanalysis, and the CBT approach to psychosis. The standard view assumes that a patient’s delusions, though false, are believed by him or her, and that the delusional objects or events are experienced as having the ontological status of something truly real (existing in the objective and intersubjective world). In our view, evidence suggests that Sean did not in fact experience his own delusions in this literalist way, but implicitly recognized their purely subjective or "virtual" nature. In light of this, we question the appropriateness of adopting the standard CBTp approach to this aspect of his psychopathology. The success of the treatment may be more intimately bound up with the relationship-building aspect (e.g., with Dr. Garrett’s skillful use of humor and perspective-taking) than with the empirical or logical refutation of his delusional preoccupations that CBTp theories would seem to emphasize. There are interesting parallels between the treatment of delusions in psychotic patients and the progression of theories in science described by such philosophers as Kuhn and Lakatos. Finally, we consider an additional aspect of the therapeutic encounter: namely, the avoidance of issues (well-advised, in our view) that could provoke or revive a sense of inferiority or humiliation in the patient (that is, of shame concerns). This is one of many demonstrations of this therapist’s remarkable skill, discernment, and capacity for empathy.