Reviewed by Matteo Colombo
Real Hallucinations: Psychiatric Illness, Intentionality, and the Interpersonal World
Cambridge, MA: The MIT Press, 2017, £32.95
Suddenly, there was a terrible roar all around us,
and the sky was full of what looked like huge bats,
all swooping and screeching and diving around the car, and a voice was screaming…
Fear and Loathing in Las Vegas (1971), Hunter S. Thompson
Imagine huge bats roaring in the clear sky, all swooping and screeching and diving around you. As you’re imagining this scene, you have now an experience of something, you are in an intentional state. Your intentional state is one of imagining, rather than one of perceiving or remembering. If you want to figure out what kind of intentional state you’re having, you don’t have to make any inference or to focus on the content of your experience. Your experience of huge bats roaring around you seems to incorporate a pre-reflective sense of the kind of intentional state you’re having.
In Real Hallucinations, Matthew Ratcliffe argues that this pre-reflective sense allows you to experience states of imagination as different from states of belief, perception, and memory, by tapping their characteristic intentional profile. For example, imagining huge roaring bats, as opposed to perceiving them, accommodates spatially and temporally unstructured scenarios, and need not involve a sense of presence, actuality, or discrepancy. According to Ratcliffe, where the characteristic profile of an intentional state gets blurry, you’ll have unfamiliar experiences that might be symptomatic of psychiatric illness. You won’t be able to figure out whether you’re imagining huge bats roaring all around you, or else perceiving, or remembering them. Thus, anomalous experiences that are generally labelled ‘hallucinations’ would ‘consist of disturbances in the sense of being in one or another kind of intentional state’—in what Ratcliffe calls the ‘modal structure of intentionality’ (p. 1).
In defending this claim, Ratcliffe pursues two goals: to lay out an account of the modal structure of intentionality and to illuminate the nature of psychiatric illness on the basis of this account. To achieve these goals, he relies on phenomenological analyses, psychiatric patients’ testimonies, and evidence from cognitive neuroscience. The resulting picture of psychiatry is that of a science of loneliness and isolation, where our experiences are understood as essentially structured, incarnate, and interpersonal (cf. Van den Berg ).
Ratcliffe’s account of ‘real hallucinations’ challenges ordinary ways of understanding what hallucinations are. Philosophers generally define hallucinations as experiences that seem exactly like veridical perceptions of external objects, but where there is actually no external object to be perceived. This definition plays a central role in several arguments in the philosophy of mind and perception (Macpherson and Platchias ). For example, the so-called argument from hallucination assumes that hallucinations are possible experiences subjectively indistinguishable from genuine perceptions of ordinary objects, and aims to establish that people are not perceptually aware of ordinary objects in veridical perceptual experiences.
Psychiatrists have similarly understood hallucinations in terms of perceptions that occur in the absence of appropriate stimulations. Nearly 200 years ago, the French psychiatrist Jean-Étienne Esquirol (, p. 93) defined a hallucination as ‘a thorough conviction of the perception of a sensation, when no external object, suited to excite this sensation, has impressed the senses’. In present day psychiatric practice, hallucinations are construed as ‘perception-like experiences that occur without an external stimulus’ (American Psychiatric Association , p. 87; World Health Organization , pp. 61, 86) and used as diagnostic markers of several psychiatric and medical conditions—including schizophrenia, post-traumatic stress disorder, and Parkinson’s disease.
In the eight chapters of Real Hallucinations, Ratcliffe argues persuasively that real hallucinations and genuine perceptual experiences are not subjectively indistinguishable and that real hallucinations are not always perception-like experiences. In fact, they present varying forms, and possess an intentional structure that is more nuanced than assumed by many philosophers of mind and psychiatrists.
Chapter 1 lays out the overall argument developed in the book, describes its methods, and outlines the main conclusions. Chapter 2 sets up some of the key concepts, and begins to discuss their application for understanding the phenomenology of schizophrenia. In particular, the chapter focuses on the notion of ‘minimal self’, which is a basic form of self-awareness that, according to Ratcliffe, essentially involves a grasp of the modalities of intentionality. This chapter also introduces the two main cases that Ratcliffe uses to unpack and illustrate his main argument, namely, auditory verbal hallucination (AVH)—often described in the psychiatric literature as hearing voices in the absence of a speaker—and thought insertion (TI)—often described as experiencing one’s own thoughts as coming from someone else.
Discussing and disentangling these two cases, Chapter 3 begins to put into focus the claim that certain kinds of experiences that are typically associated with schizophrenia consist of alterations in the modal structure of intentionality. Specifically, the claim is that a subset of AVHs and TI both consist of ‘an unfamiliar kind of intentionality that lies somewhere between thinking and perceiving, a quasi-perceptual experience of thought content’ (p. 44). Chapter 4 unpacks this claim by concentrating on episodic, content-specific alterations, and arguing that social anxiety is one powerful causal factor of AVHs. Depending on the specific determinants of social anxiety, abnormal affective anticipation of our own thoughts can variously disrupt our sense of perceiving, which is normally associated with a sense of presence and reality, of ‘here’ and ‘now’. This disruption confounds our sense of perceiving with other modalities of intentionality that are ordinarily associated with memory, imagining, or inner speech. And this confusion can result in estranging experiences of our thoughts as alien.
Chapter 5 broadens the scope to ‘more enveloping alterations of intentionality’ (p. 107). The chapter discusses the effects of traumatic experiences—namely, ‘occurrences that would cause almost anyone great distress’ such as torture (p. 115)—to show that the modal structure of intentionality depends on a ‘global style of anticipation and fulfilment’ rooted in a public world of interpersonal relationships. Ratcliffe draws on ideas from Jaspers, Husserl, Wittgenstein, and Merleau-Ponty to sharpen the notion of a ‘global anticipatory style’, which is akin to a bedrock of practical, affectively laden, habitual certainties. While pre-reflective trust in this bedrock grounds ‘how one finds oneself in the world’ (p. 113), traumatic experiences can crush it, bringing about an overall loss of trust, accompanied by a sense of a foreshortened future and of an absence of meaning in the present.
Chapter 6—perhaps the richest in the book—elaborates on the intimate relationships between global anticipatory style, interpersonal relationships, and the temporal structure of intentional states. Ratcliffe builds on concepts and arguments from previous chapters to offer a full statement of his central thesis that ‘the sense of being in a given intentional state is largely attributable to its distinctive temporal profile’ (p. 139). Chapter 7 provides an independent argument for this thesis, focusing on the experience of grief. Here, with admirable sensitivity and care, Ratcliffe explains how grief often ‘involves progressive loss of trust, social isolation, and, ultimately, the erosion of global certainty’ (p. 220), whereby one may have estranging experiences underlain by a blur of the boundaries between memory, imagination, expectation, belief, and perception.
Chapter 8 concludes by summarizing the overall argument and offering some brief remarks about two interesting implications. One meta-philosophical implication concerns the nature of belief. If the modal structure of intentionality is temporally complex, socially constituted, and interpersonally sustained, then the sense of conviction that accompanies the belief that something is the case may not be unique. If there are different types of convictions, then there are different ways of taking something to be the case. And this result would bear on a number of philosophical issues, including how to rationally respond to disagreement, the nature of the norms governing belief ascription and update, and, more generally, the nature of epistemic rationality.
The second implication concerns psychiatric practice. If experiences like TI and AVHs involve global changes in the structure of intentional modalities, disrupting one’s sense of trust and certainty, then current psychiatric categories are not apt for reliable classification and diagnosis. TI, AVHs, and several other types of experiences would not only cross ordinary diagnostic category boundaries, but also straddle psychopathological and non-clinical experiences. Ratcliffe suggests clinicians should pay attention to this intentional complexity, and conceptualize the processes underlying these experiences in terms of ‘idealized life-narratives’ that could highlight ‘situation-response patterns’ and indicate ‘potentially appropriate ways of further exploring and intervening in those patterns’ (pp. 233–4).
This suggestion is consistent with previous non-phenomenological accounts that—understanding psychiatric illness as a network of causal relationships and correlations unfolding over time—also provide clinicians with types of narrative explanation of why people suffer from certain psychopathological experiences (for example, Kendler and Prescott ). This suggestion is also in the spirit of Murphy’s () argument that the complexity observed in psychiatric illness requires constructing exemplars that include all known causal factors of a target psychiatric condition and that resemble individual patients to varying degrees.
A narrative, exemplar-based approach to diagnosis and explanation in psychiatry raises several questions. For example, under what conditions would a narrative be by itself explanatory? Explanatory of what? What kind of format should a narrative take to be useful for various psychiatric purposes, including patients’ understanding of their own condition? How should these narratives be constructed, evaluated, and revised? And how should heterogeneous ideas and strands of evidence, whether from phenomenology, biology, psychology, or clinical practice, be amalgamated into a narrative?
One concern is that without committing to and testing specific models of the functions (and not just of the lived experiences) impaired in psychiatric illness, the field would continue to be left with narrative battles about what symptoms are diagnostic of particular illnesses and what types of events cause them reliably. More generally, though phenomenological research can cast new light on the experiences associated with psychiatric illness—as Ratcliffe clearly demonstrates—one might wonder what exactly a phenomenological approach offers psychiatrists for the purposes of reliable and effective classification, diagnosis, and treatment.
These challenging issues go beyond the scope of Real Hallucinations; but they should be at the forefront of current phenomenological approaches (for example, Parnas and Zahavi ), if these approaches hope to have a salutary impact on the current methodological and epistemic state of psychiatry. Although Real Hallucinations only touches upon themes from the philosophy of science about classification, explanation, reduction, and causality, it draws several important lessons about the nature of human experience. And while its lessons are of particular importance for philosophers of psychiatry, psychiatrists, and psychotherapists with an interest in phenomenology, Real Hallucinations is a lucidly argued and richly textured book that can also offer a valuable pedagogical resource for graduate courses in the intersection of philosophy of mind, phenomenology, and psychiatry.
Work on this review was supported by the Alexander von Humboldt Foundation, which generously granted me a ‘Humboldt Research Fellowship for Experienced Researchers’ at the Department of Psychiatry and Psychotherapy, at the Charité University Clinic in Berlin.
Tilburg Center for Logic, Ethics and Philosophy of Science
American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Washington, DC: American Psychiatric Association.
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Parnas, J. and Zahavi, D. : ‘The Role of Phenomenology in Psychiatric Diagnosis and Classification’, in M. Maj, W. Gaebel, J. J. López-Ibor and N. Sartorius (eds), Psychiatric Diagnosis and Classification, Chichester, England: John Wiley, pp. 137– 62.
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