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Philosophy, Psychiatry, & Psychology 11.1 (2004) 87-94
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Talk and the Nature of Delusions:
Defending Sociocultural Perspectives on Mental Illness
discourse, social constructionism, delusions, psychosis, mental illness, context
It is very pleasing to see writers from philosophy, psychiatry and psychology, the three disciplines represented by this journal, debating the issue of delusions. The majority of the papers in this volume set out to determine the underlying mechanisms responsible for delusions. As such, they offer themselves as discussions of the etiological factors of the formation and maintenance of delusions. My paper analyzes the interactional presentation and negotiation of statements that would be considered as delusional. This led some commentators (Ghaemi 2004; Sass 2004) to argue that the analysis of talk about delusions is useful, but cannot be extended to claims about the nature of delusions. In the following section, I discuss the ways in which analyzing interactions can be useful in clinical research and practice. Subsequently, I identify and critically discuss the assumptions about the nature of delusions that underlie these criticisms and the majority of the papers in this volume.
The Usefulness of the Study of Interaction
My paper can be seen as part of a growing body of studies that attempt to elucidate the role of interactional and discursive processes in the identification and management of disorders (Barrett 1988; Coulter 1975; Hak 1989; Pollner 1975; Smith 1978; Soyland 1994). Microsociological and ethnographic studies look at the properties of client-professional interaction with the aim of clarifying the tacit skills and knowledges used in such encounters. Palmer (2000), for example, argues that the recognition of disorder is a social and interactional issue both in the sense that the judgment of disorder is based on social criteria and in the sense that diagnosis is an interpersonal process with its own inherent social order. The aim, therefore, of analyzing professional-client interactions would be to articulate the properties of this implicit social order. Other researchers argue that diagnosis is not a process of identification or recognition of disorder, but rather a process of active construction of disorder and of transforming the person to a mental patient. Barrett's (1988) analysis of the transformation of a [End Page 87] person to a "person suffering from schizophrenia" and subsequently a "schizophrenic" through interviewing and report writing is an excellent example of this kind of work.
The application of this approach to the field of delusions would attempt to address the issue of how delusions are diagnosed and managed through the interactions between the delusional patient and the clinician. In this paper and in previous work (Georgaca 1996, 2000) I showed that statements that have been diagnosed as delusional are presented and argued through using appropriate conversational strategies, drawing on socially meaningful systems of knowledge and applying appropriate rules of evidence. Moreover, I argued that there was no way in which these disagreements over competing versions of reality could be definitely settled conversationally, and that instances of breakdown in communication were due not to the delusional version being proven wrong, but to lack of explanatory frameworks within which the competing versions could be negotiated. At least in the exchanges analyzed, the criteria of implausibility, conviction, and incorrigibility were shown not to apply.
Clinicians do not customarily investigate the truth of patient claims against empirical data (Maher 1992), which means that they have to judge claims on the basis of the patient's presentation in the diagnostic interview. Because there are no technical guidelines for the assessment of truth and falsity, plausibility and implausibility, rationality and irrationality, clinicians have to rely on personal judgment. The question then is on what grounds the clinician's personal judgment is granted the status of determining the truth of someone else's claim and in what capacity clinicians are called to make such decisions. I will not pursue this argument any further here. The point I want to make is that the analysis of professional-client interactions foregrounds the active role of professionals in clinical decisions and questions the criteria upon which decisions are...