Delusions and the Postures of the Mind

The two commentators have examined and illuminated different aspects of the analysis of delusions that we have offered. Their discussions both raise points that clarify that analysis in helpful ways.

Richard Bentall (2014) makes the telling point that distinguishing the mental phenomena that count as delusions is not always straightforward and that, at the margins, there is a perennial problem with patterns of thought that seem to fall outside the realm of shared meanings that most of us derive from our experiences. The problem is evident in certain marginal conditions that come to psychiatric attention, like conversion reactions, body dysmorphic disorder, anorexia, and the many obsessions or strained personal contexts in which ordinary ideas can be overvalued (with respect to evaluations that most of us would make). Bentall is right to warn against the tendency to ‘pathologize’ and thereby classify a set of experiences as beyond what is explicable in terms of our modes of engagement with a shared life-world. There are a range of crises in our life stories that stretch us as individuals and as collectives trying to cope with the results of being shaped by our life together as vulnerable individuals. He is also right to remind us of the role of value and value judgments in our classification of mental disorder and its manifestations, a perspective that frees us from the illusion that we are describing an objective or purely natural phenomenon when we characterize a disordeer. We have embraced an implicit (quasi-)naturalism in philosophy and psychiatry that sometimes veers toward biologizing psychiatric disorders but that, in contemporary phenomenology, tries to locate belief formation as a process that goes on in human subjects as they attempt to map what they do and feel onto the meanings that our human stories make available to us within certain societal niches (such as that of ‘mad travellers’ [Hacking 1998]). There is a skill in bridging these two domains, or modes of engagement in life, and the relevant skills can be slanted in various ways. The biases may arise from psychological or neural sources so that psychiatry is usefully seen as working within a framework commensurate at least with cognitive neuroscience and our current best theories about cognitive mechanisms (Broome and Bertolotti 2009). However, the world of the imaginary transcends the individual and embraces a social and cultural context within which an individual finds resources to make sense of his or her life and therefore that world and the strains it creates for human adaptation need to be part of the picture. That said, it is worth noting that delusions are among the most reliably identifiable of abnormal mental phenomena. Although theoretically problematic, given the limitations of our ability to say exactly what delusions are, it is unusual in clinical practice for clinicians to differ with a patient’s close family members about whether or not they are deluded.

The attempt to understand psychiatric disorder leads us toward terms that threaten to marginalize the knowledge and lived experience of those classified as having mental disorders and that neglects the constructive and productive activity of human subjects in making lives that can be lived and challenging the molds that we constantly attempt to fit each other into through the “imperatives of word as law” (Lacan 1977, 106). It is only when we remind ourselves of the enigma of indwelt human meaning-making and the many different stories that can be told (and that reason can be stretched to accommodate), that we can see the dangers of words in general and our psychiatric and scientific words in particular (Drury 1996). Bentall himself notes that classifying delusions as belief is, perhaps, justified by the ‘gentle confrontation’ that often forms part of cognitive–behavioral therapy, but we ought also to note that such engagement is, whatever else, a form of recognition and respectful person-to-person engagement and that, in itself, may be a therapeutic intervention. The need for respectful and caring attention that acknowledges the integrity of who one is, however disordered one might...