In Touch With Reality?

Last night I went to Skeptics in the Pub in Sheffield, where Professor Chris French was speaking around the subject of memory and cognitive processes in relation to anomalistic psychology and the paranormal. It was a very interesting but what followed stirred my interest further. It was something that was said in the Q&A after, Chris said “It is not always a good thing to be in touch with reality”, this is an idea I want explore in this blog. It was discussed last night and I will dip into the ideas mentioned there but it inspired me to think further about it.

The main idea discussed was that reality is based on a spectrum and is largely culturally grounded. I’m sure some people in the world would consider someone who believed that some wine was the actual blood of Christ, or that shouting at the sky would make it rain are totally delusional ideas, yet with cultural relevance of a tribe or religion they make some sense. I am not saying they are logical or have any grounding in evidence, just that you would not have someone sectioned under the Mental Health Act for it.

I will warn you, I go a little off topic here, but I will be back...

This was how it was discussed last night. It is in fact more serious than you might consider, when people are detained under the Mental Health Act for the first time it is initially for a period of assessment, this can be 72 hours (if brought on a section 136 or 135 by the police to a place of safety, or already an inpatient, requiring further assessment by another doctor and a social worker) or it can be up to 28 days (Section2). Of course there are other sections of the Mental Health used to detain patients in hospital for longer periods, but the initial decision/diagnosis of a mental health problem should be done in that brief period. The reason why there is a period of assessment is that there can be many reasons for the appearance of what some people may consider a “mental health problem”. For someone to even get put on a Section 2, 3 health professionals (and or a nearest relative) must agree that it is the appropriate course of action.

Unfortunately, it can often be the use of drugs or alcohol, where use of or withdrawal from can lead to psychotic symptoms. Sometimes, particularly in the elderly an infection or illness can produce such symptoms. In such cases it is often found that once cause is established and treatment started the condition rapidly improves (although not always with drug induced psychosis, as repeated episodes can lead to slower recovery, prolonged illness and a diagnosis of schizophrenia) further detention in hospital is not usually necessary.

In other cases, and here is why I am on this topic, an interpreter needs to be sought and explanations looked into for behaviours that have or are still occurring. I have seen cases where clinicians have believed phrases/actions to be evidence of psychosis, but with further knowledge found that they are actually expressions of grief/religion in other cultures. In our catchment area there are a lot of refugees/asylum seekers, this means that not only do we get a large variety of languages/cultures to understand but also a lot of people who have been through traumatic events and may seek mental health services. Understanding such cases, does take some time and digging for relevant information. The reason I bring this up, is that we should all be aware of our own cultural biases. What we may judge as abnormal or even insane behaviour may be perfectly “normal” (for want of a better word) in another culture, just as some behaviours we see as everyday things may be perceived differently in another country. We should all make an effort to be aware of such perceptions and judgements. I am as guilty as the next person of such bias; even the other day as I tucked into my sausage sandwich, I was shocked at my friend Geoff for eating okra and chilli for breakfast with his fingers, but in Ghana that was perfectly normal. (A less extreme example I know, but I am aware of confidentiality issues).

Now back to reality (I mean back on topic)...

As stated before it should be seen as a scale, and in fact some loss of touch with reality can be a good thing. As Professor Chris French said last night, you or I have an unrealistic optimism; we believe good things will happen in life (lottery win, pay rise, better job, or fall in love) where as when it is looked at depressed people have it more accurate than us. I don’t want us to all get depressed, optimism is good, but it is not based on facts and figures, on evidence, therefore it is not based on reality. Yet it is a cultural norm, for thousands and thousands of people to play the lottery every week, something I believe some cultures would neither approve of nor understand when you consider what could be done with that kind of money. I want to continue to hope for a better job/life but I have no evidence it will happen (I do not however believe in fate, I do believe in consequences and coincidences, and if the right ones occur I may have some unexpected wonderful experiences, I choose to look at life this way instead of the pessimistic way).

Some people like to be a little eccentric, different, odd maybe. And in my opinion (and I am sure there are numerous references for it) there are people who like being “a little bit mad” (I know not a PC term, but let me explain).There are people with personality traits that do not fit “the norm”, they may appear a little odd, sometimes make people uncomfortable, but they get on with life and do no one any harm.

I have met several patients who have had mental health problems for a number of years, this is something they learn to cope with in their own unique ways, yes we offer advice, support, education and medication, but they still have to cope on a daily basis. Occasionally we may suggest a new treatment to a patient, at this point I have had discussions where a patient has to consider what it would be like to not “have voices” or fixed beliefs, something which can be frightening and incomprehensible, especially if they cannot remember how they were prior to being unwell. Some people as they recover have even reported missing their “voices” (not all auditory hallucinations are negative or abusive, some are supportive although this is less common) a sense of loss. I know this is more about coping with change and regaining “touch with reality” but we must consider that it is not always what the person wants it is sometimes what society wants, and therefore a much more difficult transition.

People with Bipolar disorder often report that they like being “slightly high”, that is just on the edge of a manic episode, and why not? There is elevation of mood, motivation, energy, creativity, a lack of need for sleep, however as mania worsens there is even less sleep and a detrimental effect on health including irrational behaviours (which can include spending, sexual dis-inhibition, mood swings, aggression, risk taking). There is point at which mania is for some people, rather nice, imagine an overwhelming optimism and belief in your own abilities (not necessarily an accurate belief), unfortunately health professionals and relatives (and many patients) know this stage does not last and that medication and support are needed to stabilise the condition or treat the full manic episode, this can mean a substantial period in hospital.

I know I have wondered off topic (again) from what we discussed at Skeptics in the Pub, into mental health but as was stated last night, being in touch with reality or not is absolutely fine, what matters is how it impacts on your life and the lives of those around you. You cannot believe you have the right to run the streets with a machete demanding things, and I’m sure there would be concerns if you would not leave your house due to fear of alien attack, to the point where you did not buy food. But for some people to believe in a man sitting on a cloud in the sky watching over them and they go to a building to talk or sing about this, or really believe that next week they might win the lottery if they are “lucky”, then fine, I can tolerate that. I can’t say it is logical or an opinion I share (although I have been guilty of buying random lottery tickets infrequently, even though I know the maths), but sometimes I may hold such beliefs even with flawed logic. A little blind optimism goes a long way (sometimes).

As a skeptic the way in which I find this unacceptable is if someone is provided with evidence for/against such beliefs (or fails to provide any evidence, but state they know it is true), and then they continue to hold their views. If a patient at work were to introduce me to the alien that had abducted him, or show me the implant via an x-ray, then of course I would believe them and help them barricade themselves in a suitably protected place, I would not give them anti-psychotic medication. I do jest slightly, there are extremes, believing in aliens is not necessarily evidence of mental health problems (I remain agnostic about them I have seen no evidence they exists, but am aware that there are probabilities suggesting it is possible). It is where there is significant impact on life despite a lack of evidence, where such beliefs are detrimental to a person’s or other people’s health or safety that steps need to be taken, whether it be the diagnosis of a mental health problem or correction of a flawed cultural system (e.g. the way in which religion impacted on and still does impact on education).

As stated at the beginning of this very long ramble, it all depends on cultural relevance as well as impact on daily life and other’s lives. I don’t think I do ever want to be truly logical all of the time, like some kind of Vulcan (yes I know they are fictional too). I like my occasional naivety, my small irrational beliefs. I do still press the button at a pedestrian crossing over and over, knowing it will not make the lights change faster. I don’t mind that some people hold stronger irrational beliefs than me, I do mind if it gets the way of people’s health or well being, so someone believing in faith healing for example and avoiding medicine in order to seek such “treatment” and encouraging others to do so, I cannot condone at all and I would openly object to. Yes, in an ideal world everyone would be a skeptic, but I don’t think we can be, nor should we be logical about everything all of the time, a little loss of touch with reality can be quite refreshing.

Thanks if you made it this far, feel free to correct me, disagree, agree. (please don't be too harsh I am poorly today).