Hallucinations

Crit_rat asked a question about hallucinations on Twitter:

Is an inner monologue technically an auditory hallucination?

I replied: 

No. Hallucination is a pseudo-scientific psychiatric term for self conversation that is unwanted for some reason, see Chapter 1 of “The Meaning of Mind” by Thomas Szasz and

Szasz’s position is that psychiatrists have been given the power to lock people up without trial in mental hospitals and to drug them without their consent without trial and that this is a violation of their civil liberties. In the UK in 2018-2019 the NHS reports that 49988 people were detained under the mental health act so this isn’t a minor violation of civil liberties. Psychiatrists use this power as a tool of social control to deal with behaviour that they deem to be undesirable and they call that undesirable behaviour mental illness. This undesirable behaviour may or may not be criminal. A hallucination is self-conversation that is unwanted by the person having it or by somebody else such as a relative or psychiatrist. The idea of mental illness is an excuse employed strategically by psychiatrists, mental patients and others to pretend that these institutions are scientific. Szasz has made suggestions for reform that have been rejected wholesale by psychiatrists and the government because they are attempts to reform toward individual liberty and responsibility. A longer summary with some suggested reading can be found in my Fallible Living Szasz essay.

The psychiatrist Michael Golding replied:

I hope a friend of yours is never in the ICU and hallucinating, while pulling out his life-sustaining breathing tube, when the doctor says that his hallucinations of someone saying he is being choked with a feeding tube is “unwanted”…”self conversation”

I replied:

If a patient has a breathing tube down his throat he can’t speak. So how do you know why he’s pulling it out? Also, the case you describe involves self conversation and you don’t want it to happen. So it doesn’t refute Szasz’s description.

Golding replied again:

They can write, you often can tell behaviorally that people are hallucinating, and they can tell you later, after you get them on the IV meds that stop the hallucination and returns them to their right mind.

I’m not keen on continuing this discussion on Twitter because it’s not good for discussion: explaining ideas in 280 character chunks with bad threading is not a good setting for discussion. I have offered to discuss the issue off Twitter on this blog or in any other venue he would prefer but Golding hasn’t taken me up on that offer. I’m still not very clear on Golding’s position. I think he disagrees with Szasz’s position, but  he hasn’t pointed to a particular essay, paper or book that provides a criticism of Szasz that he’s willing to explain and defend. His tweets remind me of the statemnent on Rearden Metal by the State Science Institute described on p. 183 of Atlas Shrugged in Part One, Chapter VII.

Golding also hasn’t clearly explained the relevance of this example. If a person is taking an action, such as pulling out a breathing tube, then he has a reason for doing that. His arms aren’t flailing around randomly. He is acting to produce a specific result. He has thought about what he is doing. That thought might be as simple as “I don’t like having this tube, so I’m going to pull it out” or it might be more complicated. All you know about what he is thinking is a result of trying to explain his actions and what he communicates about those actions in speech and writing. If he is trying to pull out the tube then he has decided to try to pull out the tube. If a doctor doesn’t like that decision, then these thoughts and actions are unwanted by the doctor. Calling the patient’s thoughts a hallucination is an example of “hallucination” being used as a label for unwanted self conversation. Golding doesn’t state whether he agrees or disagrees with this way of looking at the issue.

I think Golding’s position is that pulling out the tube is undesirable. I think the desirability of the tube being removed depends on the context. If a person wakes up in a hospital bed with a breathing tube he might be confused about what’s going on and try to pull out the tube because it is uncomfortable or because he thinks it is a feeding tube and doesn’t appreciate that he might die if he removes it. Under such circumstances it might be a good idea to restrain the patient from doing that until you have explained the situation to him. If he knows what the tube is and decides to remove it that’s a different situation and nobody should stop him from removing it by force. I think a person shouldn’t be forced to live because another person wants him alive. Does Golding want to force people to stay alive? Is he aware of Szasz’s criticisms of trying to prevent suicide by force and does he have an answer to them?

There is another complication to this story: people can lie and in this case the patient may have an incentive to lie. A person can be involuntarily committed if he attempts suicide. So if somebody is caught in the middle of a suicide attempt that involves pulling out a breathing tube he might say that he thought it was just a feeding tube to try to avoid being committed.

I have another question about this example. The patient claims that he thought the breathing tube was a feeding tube. Did the patient have previous experience with feeding tubes? If so, did he have a feeding tube voluntarily or was he forced to have a feeding tube?

I have nailed this particular piece of jelly to the wall to the best of my ability. But a clear explanation would make it easier to work out what Golding’s position is and whether it answers Szasz’s criticisms of psychiatry and the idea of hallucinations.