My guest today is Dr Chris Letheby, a philosopher working on issues related to psychedelic drugs, who is currently a lecturer in philosophy at the University of Western Australia and a postdoctoral researcher at the University of Adelaide. Chris is also the author of the book Philosophy of Psychedelics, which was published in 2021 by Oxford University Press.
In this conversation we touch on the account given in Chris’ book of the therapeutic benefits of psychedelics, and then go deep into Chris’ account of the phenomenology of psychedelics. This conversation was a lot of fun, and I hope you enjoy it as much as I did.
I also want to explicitly recommend Chris’ book. I think it does an excellent job of drawing together a whole range of different types of research to provide a clear and sophisticated framework for understanding how psychedelics have their therapeutic and transformational effects, and the consequent philosophical implications.
Show Notes
2:45 – The question that Philosophy of Psychedelics is organised around: “Is psychedelic therapy simply foisting a comforting delusion on the sick and dying”?
6:15 – Chris’ theory about what is happening in the psychedelic experience, the hierarchical self-binding account.
16:20 – How the hierarchical self-binding theory accounts for the phenomenology of the mystical experience.
33:10 – How the hierarchical self-binding theory accounts for other remarkable aspects of the psychedelic/mystical experience – the sense that everything is conscious and the sense that the experience is True.
43:50 – How the hierarchical self-binding theory accounts for other remarkable aspects of the psychedelic/mystical experience – the sense of sacredness and the fundamentalness of love.
50:20 – What’s coming up for Chris and what he hopes to see in the next decade of psychedelic research.
Today we speak again with Professor Josef Parnas, Professor of Psychiatry at the University of Copenhagen and a co-founder and Senior Researcher at the Danish National Research Foundation: Center for Subjectivity Research.
For some 40 years, Professor Parnas has worked as a clinician and conducted research into the schizophrenia spectrum with an emphasis on the phenomenology of schizophrenia. In our first conversation we discussed the implications of taking the phenomenology of schizophrenia seriously, and covered topics such as importance of clinical experience, and adequacy of current systems to classify psychopathology.
But after the interview I realised that we didn’t really discuss the phenomenology of schizophrenia itself and felt that I had missed an opportunity to learn from someone with so much experience. So in this episode, I ask of a lot of basic questions to better understand what schizophrenia is and what life is like for those with it.
Show Notes
1:20 – On the prototypical case of schizophrenia.
26:15 – On psychosis and it’s relationship to schizophrenia
32:10 – On psychosis in schizophrenia vs. psychosis in other conditions.
38:00 – What catalyses psychotic episodes?
44:30 – Is psychosis itself adaptive?
49:00 – On the marked difference in quality of life outcomes between different cultures.
55:00 – On the link between Autism and Schizophrenia
1:20 – On the prototypical case of schizophrenia.
One interesting point about schizophrenia is that it can be difficult to date its onset. Although onset of flamboyant psychotic symptoms and diagnosis with schizophrenia typically occurs somewhere around the early 20s, and there is often a prior history of contact with psychological/psychiatric services and differences in behaviour and the person’s experience that occur well before diagnosis. These differences and difficulties are related to being a subject in the world. For example, even as a, say 11 or 13 year old, the person would often feel profoundly different and cut-off from others, even if they don’t display conspicuous behavioural differences. Interestingly people with schizophrenia may find it difficult to verbalise in what sense they are profoundly and fundamentally different. This feeling of a lack of naturalness in and attunement to the world is reflected in the person being perceived as peculiar or eccentric, and sometimes leads to a interest in metaphysical or philosophical issues.
The onset of psychosis itself, is linked to an increasing sense of self-alienation. For example, the patient starts to experience their thoughts as being ‘at a distance from themselves’ and eventually as not belonging to themselves. This may lead to a sense of revelation that they are in contact with another dimension of reality that is not accessible to other people (and such a sense is often experienced by those with schizotypal traits without psychosis). Other schizophrenic symptoms such as the sense of have thoughts inserted into their head, and of one’s thoughts/actions being controlled (ie. passivity phenomena) is also related to this increasing sense of self-alienation. Delusions are also related to the growing sense of self-alienation, and are often developed while the person realises that something is happening, but doesn’t understand what is happening.
For most patients, schizophrenia is a fluctuating condition (with or without medication). Only a minority of people deteriorate into a chronic debilitated state.
26:15 – On psychosis and it’s relationship to schizophrenia
Psychosis is nearly impossible to define satisfactorily. People may have the auditory hallucinations characteristic of psychosis, but should not be considered psychotic if they recognise them as such and are able to function in the world. Only when such private experiences are taken to be the objective, shared world and are then acted upon is there a clear case of psychosis. And indeed, many people who are discharged as non-psychotic will continue to have unusual experiences but are able to separate their own experiences from those of the socially shared reality.
32:10 – On psychosis in schizophrenia vs. psychosis in other conditions.
The experience of psychosis itself is similar between its occurrence in schizophrenia and in other conditions. However, you might say that before psychosis, the experience of the person with schizophrenia is closer to the psychotic state than that of non-schizophrenic people.
38:00 – What catalyses psychotic episodes?
Drug abuse can precipitate schizophrenia, but often there are questions about the direction of causality. Self-medication through dug abuse is common amongst people with schizophrenia. Additionally trauma, emotional deprivation (as was more common in the foster homes of past generations) or the loss of another person on whom the person is in some way dependent, is often a catalyst.
44:30 – Is psychosis itself adaptive?
I asked this question after coming across this paper: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00237/full
In contrast, Josef doesn’t consider there to be any real adaptiveness to psychosis itself.
49:00 – On the marked difference in quality of life outcomes between different cultures.
Research almost 30 years ago by the WHO suggested that people in less developed countries had a better prognosis than people in more developed countries. However, such studies are extremely complicated. But the social environment is certainly important for life outcomes for those with schizophrenia. People with schizophrenia will do better in more tolerant social environment than a rigid and hostile one. So we could expect a more productivity-focused social environment to lead to worse outcomes for people with schizophrenia.
55:00 – On the link between Autism and Schizophrenia
Josef does not think there is a link between the two conditions. This is not surprising given Josef’s emphasis on anomalous self-experiences – a recent paper has pointed to very different self-experiences in ASD and schizophrenia (https://academic.oup.com/schizophreniabulletin/article/46/1/121/5485220). He is also sceptical about the dramatic increase in prevalence of ASD in recent years, mentioning the work of Ian Hacking (for example, https://www.lrb.co.uk/the-paper/v28/n16/ian-hacking/making-up-people)
Today we speak with Professor Josef Parnas, Professor of Psychiatry at the University of Copenhagen and a co-founder and Senior Researcher at the Danish National Research Foundation: Center for Subjectivity Research. Professor Parnas has been involved in research into the schizophrenia spectrum for about 40 years, and by using a phenomenological approach, has come to focus on the anomalous self-experiences associated with the schizophrenia spectrum.
In this conversation we discuss how we should think about schizophrenia, phenomenology and the importance of clinical experience, and systems to classify psychopathology.
Show Notes
0:00 – On Josef’s background.
3:25 – Josef’s overview of what we know about schizophrenia.
10:30 – Contrasting the core of schizophrenia from the symptoms.
21:45 – On the compatibility of predictive Bayesian computation accounts and phenomenological accounts of schizophrenia.
36:50 – Does Josef find the research on meditation or psychedelics interesting, given his interest in alterations of self-experience?
38:20 – Why Josef is not hopeful that dimensional classification systems for psychopathology?
50:15 – Alternatives for students or researcher who do not have the option of gaining direct experience with schizophrenic populations.
52:00 – On what historical European psychiatry has to offer contemporary psychiatry.
0:00 – On Josef’s background.
Josef was trained as a medical doctor at the University of Copenhagen, and then completed his internship at a hospital running important studies that showed that schizophrenia has an important genetic basis. He has worked simultaneously in clinical and research capacities throughout his career.
He arrived at his interest in phenomenology because of his interest in psychopathology. The phenomenological perspective was the most mature account of psychopathology, and was very much mainstream until DSM-3.
3:25 – Josef’s overview of what we know about schizophrenia.
Thinks that schizophrenia is not well represented by the current medical model, which emphasises chronic psychotic symptoms, such as hallucinations and delusions. This is likely due to the desire of recent DSM efforts for reliability of diagnoses. The core features of the schizophrenia spectrum, which include distortion of subjective life and disorders or expressivity, are relatively neglected perhaps because they tend to require clinical experience to reliably identify.
Schizophrenia is more than just the chronic condition identified by the DSM. One piece of evidence that suggests schizophrenia is a spectrum rather than just the severe diagnosable condition is that only a minority of patients with diagnosable schizophrenia experience a deteriorating chronic course, many experience a remitting course and a significant proportion (20-25%) of those that would qualify for a diagnosis are never treated or seek medical help at all. Then there are milder parts of the spectrum that wouldn’t qualify for a schizophrenia diagnosis, which again, do not typically seek psychiatric help. Also, there are links between vulnerability to schizophrenia and creativity.
10:30 – Contrasting the core of schizophrenia from the symptoms.
There is something qualitative about the symptoms of schizophrenia. A schizophrenic delusion or hallucination is easily distinguished by the experienced clinician from the delusions or hallucinations symptomatic of other conditions. Josef considers the nature of these symptoms to be reflective of differences in the subjective experience, which he considers the core of schizophrenia colouring the manifest symptoms. Said differently, it is not the case that the symptoms in schizophrenia are not simply occurring to a person that otherwise experiences life as a neurotypical person does. The differences occur right down to a fundamental level of the person’s subjective experience, and these differences pre-date and may give rise to the more obvious clinical symptoms.
Josef tells a story of a client of his that was surprised to learn that most people experience thoughts as their own, as opposed to existing in some sort or collective space as experienced by the client.
Therefore, to understand schizophrenia, we need to be thinking in terms that are pervasive and fundamental, rather than modular.
21:45 – On the compatibility of predictive Bayesian computation accounts and phenomenological accounts of schizophrenia.
Intuitively, Josef is attracted to such accounts.
26:10 – Are schizotypal traits adaptive?
People with schizotypal traits often don’t share the naturalness with which neurotypical people relate to the world. And if you don’t take the obvious for granted, this may facilitate a curiousity about the world and lead to greater creativity. And indeed, there is a documented link between schizophrenia (and relatives of those with schizophrenia) and creativity.
Here is a link to the study Josef mentioned on the prevalence of schizophrenia in the relatives of university scientists.
Robert Sapolsky’s lecture on schizophrenia: https://www.robertsapolskyrocks.com/schizophrenia.html
Josef’s translation of Hans Gruhle’s 1929 work, ‘The schizophrenic basic mood (self-disorder)’.
33:25 – On the disorder of self in schizophrenia.
Josef thinks that the disorders of self-experience in schizophrenia, are coming to be increasingly recognised. In fact, disorders of self-experience will be mentioned in the new ICD-11.
38:20 – Why Josef is not hopeful that dimensional classification systems for psychopathology?
Clinicians say that they only need ~25 diagnostic categories, not the ~400 in DSM-5. The reliance on well defined diagnostic criteria (in the DSM and ICD) and the discarding of phenotypic/prototypic descriptions, has resulted in an unending proliferation of diagnoses. Josef is also sceptical that a dimensional approach will be adopted by clinicians – “clinicians like categories”.
Instead, Josef thinks the best solution might be to have different classification systems depending on the context/purpose.
50:15 – Alternatives for students or researcher who do not have the option of gaining direct experience with schizophrenic populations.
Josef recommends a number of books to gain insight into the phenomenology of schizophrenia, including;
Today we speak with Professor Robert Krueger, Distinguished McKnight University Professor, Hathaway Distinguished Professor, and the Director of Clinical Training in the Department of Psychology at the University of Minnesota. Professor Krueger’s work spans the fields of personality and personality disorders, psychometrics, and genetics, and is centred on developing an empirically-based system of grouping and delineating psychopathology.
This is a topic that I think is important to the way we think about mental health and conduct research into it. And I couldn’t hope to have to have a more qualified guest to discuss the topic with. Professor Krueger was a member of the DSM-5 Personality and Personality Disorders Work group, and is an architect of the Hierarchical Taxonomy of Psychopathology a new, dimensional classification system of psychiatric problems.
Show Notes
1:20 – On Robert’s background
2:55 – On the problems associated with the DSM diagnostic procedure
5:05 – How did we end up with the DSM given how readily the associated problems are observed, and given the transdiagnostic approach of early psychotherapists?
8:20 – On the pendulum swinging back the other way now.
11:50 – An outline of the HiTOP (Hierarchical Taxonomy Of Psychopathology) approach to diagnosis and categorisation.
17:20 – On why traditional categorical diagnoses appear in the HiTOP?
22:25 – On the similarities and differences of Research Domain Criteria (RDoC)
26:40 – On other approaches to deriving an empirically derived nosology, apart from HiTOP and RDoC.
28:55 – Will the shift to an empirically derived nosology be a big change for clinicians?
33:20 – Thinking about an example involving multiple diagnoses, from a HiTOP perspective.
37:15 – Does the move toward an empirically derived nosology have any implications for debates around the over-pathologising of normal human experience?
41:00 – What advice does he have for students?
2:00 – On Robert’s background
Robert was trained as a clinical psychologist, obtaining a PhD in clinical psychology. His interest in diagnosis and categorisation goes back to early experiences struggling to apply the standard diagnoses to his clients.
2:55 – On the problems associated with the DSM diagnostic procedure
Under the DSM, diagnoses are made when someone meets a certain threshold of diagnostic criteria from a list of diagnostic criteria. Under this system there can be considerable heterogeneity within categories (people with different symptoms receiving the same diagnosis). Similarly, people tend to meet the criteria for more than just a single diagnoses. This is known as the co-morbidity problem, and limits the usefulness of a diagnosis for planning appropriate treatments.
5:05 – How did we end up with the DSM given how readily the associated problems are observed, and given the transdiagnostic approach of early psychotherapists?
DSM-3, published in 1980, was a significant turning point. Earlier editions of the DSM had only descriptive paragraphs instead of well delineated criteria sets (which was also problematic). It is only by doing research with such criteria sets that their problems clearly emerge.
8:20 – On the pendulum swinging back the other way now.
Robert identifies the main reasons why people in the research community are supportive of a move to a more empirical diagnostic system as due to the disappointing search for biomarkers of psychiatric conditions. For clinicians, it is the lack of informativeness of a diagnosis for planning appropriate treatments.
11:50 – An outline of the HiTOP (Hierarchical Taxonomy Of Psychopathology) approach to diagnosis and categorisation.
HiTOP is an effort to follow the evidence of how the symptoms associated with psychiatric conditions are organised. The resulting view is one where people’s experience is seen to fall along different dimensions, rather than in clearly different categories. The dimensions are considered to be organised hierarchies from signs and symptoms at the lowest level to a general psychopathology factor at the highest level.
17:20 – On why traditional categorical diagnoses appear in the HiTOP?
The presence of traditional categorical diagnoses in HiTOP, such as Major Depressive Disorder and Bipolar Disorder, partially reflects that fact that most research has been done along the line of such categories. However they are also intended to help with the transition from the current approach to an empirical approach.
In time, the use of such diagnoses may fall away if such a change was supported by the evidence.
22:25 – On the similarities and differences of Research Domain Criteria (RDoC)
The RDoC project is an initiative being developed by US National Institute of Mental Health. It was initiated in response to the same dissatisfactions with the DSM criteria that motivated HiTOP. However, in comparison with HiTOP, RDoC is more focused on biological mechanisms and makes less concessions to ensure continuity and an easy transition from the current approach.
RDoC and HiTOP should be seen less as competing approaches, and more as complementary approaches that will dialogue and converge on a consensus conception of psychopathology.
26:40 – On other approaches to deriving an empirically derived nosology, apart from HiTOP and RDoC.
There are a variety of approaches currently being explored with the hope of deriving an empirically derived nosology. Network approaches focus on the relationship between different symptoms. A key difference between network approaches and HiTOP is that network approaches don’t give much focus to higher levels of the hierarchy proposed by HiTOP.
28:55 – Will the shift to an empirically derived nosology be a big change for clinicians?
In some ways, especially around record-keeping and insurance, the move to a HiTOP-type system may require significant changed. But in terms of how they think about and approach treatment, clinicians may already operate in a way that is consistent with a HiTOP-type system. For example, they may often forego a formal diagnostic assessment as they consider it to have little clinical utility. Instead, they may think about their client’s difficulties in broader terms than DSM-5 labels, something like the HiTOP spectra (internalising, externalising and thought disorders).
33:20 – Thinking about an example involving multiple diagnoses, from a HiTOP perspective.
The example involved a case where a person presents with symptoms of anxiety, depression and substance-use disorder. There is little difference in the way one would approach treatment (again, testament to the fact that most clinicians don’t use DSM-5 diagnoses to guide treatment). However, a notable opportunity that comes from thinking in a HiTOP-consistent way, is to identify processes that are relevant to a number of diagnostic categories.
37:15 – Does the move toward an empirically derived nosology have any implications for debates around the over-pathologising of normal human experience?
For one thing, efforts to derive an empirically derived nosology have highlighted that there is no bright line between psychopathology and normal variation. This spectrum-based thinking, instead of categorical thinking, highlights that it is convention that dictates when to intervene, rather than a simple case a disease is present and therefore an intervention is warranted/necessary.
41:00 – What advice does he have for students?
Pursue your passion. This might seem cliche, but for Robert, doing something meaningful and interesting makes it easier to persist through the difficult times.
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Announcements
There is currently an opportunity to volunteer as a research assistant with the Black Dog Institute. They are particularly after volunteers who can visit Walcha and/or Glen Innes (travel costs reimbursed), though opportunities exist in other areas of New South Wales too. The positions will support The Future Proofing Study, which is the largest mental health prevention study ever undertaken in Australia. I spoke with the Chief Investigator of The Future Proofing Study in Episode 10 (https://www.mindstewpodcast.com/e010/). Details of the position can be found here.
Today we speak with Dr. Rebecca Brewer, Senior Lecturer in Psychology at Royal Holloway, University of London. Rebecca studies social and emotional abilities across a range of clinical and typical populations, and how interoception (the perception of the internal states of one’s body) is related to these emotional and social abilities.
Interoception is a topic that I’ve been finding fascinating lately. Interoception is important to many processes fundamental to what makes us who we are, from homeostasis to subjective experience itself, from decision making to psychopathology.
In this conversation, we focus particularly on the relation of interoception to psychopathology, an area where Rebecca has done interesting work and proposed big ideas.
Show Notes
1:20 – What is interoception and why study it?
4:25 – On the relevance of interoception to psychopathology.
6:25 – On interoception abnormalities as the p-factor.
9:45 – Does the relationship of interoception abnormalities to psychopathology appear causal?
13:00 – On treatments targeting interoceptive ability.
21:45 – On what Rebecca hopes the next wave of interoception research
26:00 – On the importance of interpretation of interoceptive signals
28:30 – On whether interoception is an area of interest for positive psychology
30:30 – On the focus of upcoming research for Rebecca’s group
39:40 – What Rebecca wishes she new when she was a student.
1:20 – What is interoception and why study it?
Interoception is the perception of signal arising from within the body. Sometimes the definition is widened to include stimuli that share similar neural pathways, such as slow sensuous touch.
Rebecca’s early research focused on ASD and alexythymia (difficulty understanding your own emotions), which led her to interoception.
4:25 – On the relevance of interoception to psychopathology.
Many different clinical populations struggle to understand their own emotions. Additionally, it seems linked to other disorders unrelated to emotional recognition, such as eating disorders and substance use disorders.
6:25 – On interoception abnormalities as the p-factor.
The p-factor is idea that there is a single factor that might underlie susceptibility to psychopathology in general, analogous to the g-factor in intelligence. Rebecca did work with Geoff Bird and Jennifer Murphy suggesting that the p-factor might relate to interoception. They suggested this as interoceptive abnormalities have been seen across a very wide range of psychopathologies (including depression, anxiety, OCD, schizophrenia, eating disorders, substance use disorders).
9:45 – Does the relationship of interoception abnormalities to psychopathology appear causal?
It’s unclear at this point. In some cases interoception abnormalities can lead to psychopathology, but the relationship is likely bidirectional.
13:00 – On treatments targeting interoceptive ability.
There are different aspects to interoceptive ability. Hugo Critchley and Sarah Garfinkel proposed the following aspects:
Accuracy/sensitivity: your objective ability perceive a particular internal signal. eg. Accuracy in counting heartbeats.
Sensibility: how much do you report noticing and focusing on your internal states.
Metacognitive awareness: Your accuracy of your perception of your interoceptive accuracy/sensitivity.
There are treatments that train both sensibility (focusing more on internal signals) and accuracy. Sensibility can be targeted through mindfulness-based interventions. Accuracy can be targeted by providing external feedback at the same time a an internal signal, most commonly heartbeart.
It is not yet clear whether training heartbeat perception translates to improved perception of other interoceptive signals, and the other psychological processes that involve interoception, such as understanding emotions, empathy, processing risk and reward.
21:45 – On what Rebecca hopes the next wave of interoception research
On of the main things is to develop better tests of interoception. And, of course, larger studies looking at whether altering interoceptive ability changes cognitive functioning and psychopathological symptomatology.
26:00 – On the importance of interpretation of interoceptive signals
Alongside the objective accuracy one’s ability to perceive interoceptive signals, the interpretation of perceived signals is important. Interoceptive signals can be over-interpreted, as in the case of someone with anxiety who might think that they are having a heart attack when it is really just a slight increase in their heart rate, or under-interpreted, as in the case of those with alexythymia who tend to report heart attacks too late.
28:30 – On whether interoception is an area of interest for positive psychology
There have been some studies on non-clinical populations, looking at for example the relation between interoceptive ability and decision making. However, the majority of the work is clinically focused.
30:30 – On the focus of upcoming research for Rebecca’s group
One thing that Rebecca’s group will be looking at the link between interoception and social perception. For example, does your ability to perceive whether you are tired correlate with your ability to perceive if someone else is tired. This work could inform interpersonal interactions in medical and care-based professions, and any work where empathy is important.
39:40 – What Rebecca wishes she new when she was a student.
Rebecca wishes she new how much freedom and flexibility academia provides, both in terms of collaborators and research areas. Also, that not every piece of work needs to entail a groundbreaking idea. And that she had a better understanding of the publication process.
Today we speak with Dr. Maria Kangas, Associate Professor of Macquarie University’s Centre for Emotional Health.
Maria is a registered psychologist with dual endorsements from the Psychology Board of Australia in Clinical and Counselling Psychology. Maria is also Director of the Clinical Psychology program at Macquarie University. Her research has focussed on coping strategies and emotional regulation relating to stress/PTSD, anxiety and mood disturbances in trauma and medical (e.g., cancer) populations, across the lifespan.
*Please accept my apologies for the recording quality. There are a number of moments where a faulty internet connection has undermined our VOIP program and resulted in a recording that was clipped in a few places.
