Delusions and Discourse: Moving Beyond the Constraints of the Modernist Paradigm

This special issue provides a good opportunity to reflect on the range of views about delusions,¹ and it is good to see all the authors taking the issue of how to approach this topic seriously. Here I wish to argue that the traditional psychiatric view of delusions is problematic. In the first half of this article I will group my comments on the issues raised by the papers by Klee and Bayne and Pacherie together as I think that, for their differences, they share modernist philosophical assumptions. I will argue that the modernist paradigm runs into considerable problems in considering beliefs felt by some to be unusual and I will go on to argue that we need to move beyond this paradigm and embrace different approaches, of which the work by Georgaca is an exemplar.

The Trouble with (traditional Views of) Delusions

The traditional psychiatric view of delusion has come under increasing attack over recent years. As Georgaca has noted, a number of problems with the assumptions in definitions of delusion can be identified when they are viewed from a social constructionist perspective (Georgaca 2000, 2004; Harper 1992, 1996; Heise 1988). For convenience I will group these under four main headings.

They Are Based on a Naively Realist View of the World

The criterion of inaccuracy or falsity implies that deciding on the veracity of a belief is a relatively unproblematic matter. However, the reality of claims does not always seem so important in judgments about whether a belief is delusional or not. For example, there is little evidence that mental health professionals systematically investigate the basis for people's beliefs; rather, they decide whether a belief is plausible. Thus Maher has argued that the assessment of the plausibility of beliefs is "typically made by a clinician on the basis of "common sense," and not on the basis of a systematic evaluation of empirical data" (1992, 261). He notes that it is not "customary to present counterevidence to the patient; it is not even common to present vigorous counterargument" (1992, 261) and there appears to be some empirical evidence of this (McCabe et al. 2002). Here then, we begin to see how psychiatry, while claiming to have the power to judge the truth of beliefs on the basis of its status as an empirical scientific discipline, can be seen to make judgments on the basis of common sense and taken-for-granted social and cultural assumptions.

Some commentators have suggested that delusions should be identified less by whether they seem to accord with reality but more by whether a person gives evidence for their belief (Gillett 1995; Spitzer 1990). However, this seems to be based on an idealized view of how people manage their beliefs in everyday life. For example, I would question how many of us have evidence for many of the beliefs (e.g., political, ethical, religious, etc.) we hold dear; indeed it would be hard to think of what evidence we could have for some of them (e.g., religious and ethical beliefs). Some recent work has suggested that the diagnosis of delusion is made on the basis of how people with delusions talk and interact; for example, some have argued that they do not appear to appreciate the hearer's point of view (Palmer 2000). However, here and in previous work, Georgaca (2000, 2004) has shown that people with delusions are able to talk about and negotiate disagreements about their beliefs and that many disputes of fact cannot be settled in conversation.

People Said to Have Delusions Are Seen to Vary in the Conviction With Which Those Beliefs Are Held

There is evidence that people considered to be deluded vary in the conviction with which they hold beliefs (Garety 1985) and can also be persuaded to modify their beliefs if this is conducted in a sensitive and collaborative manner (e.g., Chadwick, Birchwood, and Trower 1996). This...