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Deconstructing Paranoia:

An Analysis of the Discourses Associated with the Concept of Paranoid Delusion

David J. Harper

D.Harper@uel.ac.uk

Department of Psychology, University of East London

 

A thesis submitted in partial fulfilment of the requirements of the

Manchester Metropolitan University for the Degree of Doctor of Philosophy

June 1999

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ABSTRACT

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This thesis details assumptions implicit in discourse about paranoia and describes the interests and consequences of different discursive frameworks. It is organized into three parts.

In the first part, I focus on the production of paranoia in a range of cultural contexts using a form of discourse analysis to explore both how a history of paranoia is constructed and to identify some of the interests at work in that construction. Then I go on to analyse discourse about paranoia in popular culture and look at how paranoia is an identity which can be taken on or used to position the Other which leads to the de-legitimisation of their views. Finally, in this section, I use a form of deconstruction to examine professional texts about paranoia drawing out some implicit oppositional assumptions.

In the second part I again use discourse analysis to examine three topics which emerged in interviews with nine users of psychiatric services and twelve professionals who have worked with them. I explore how emotion is related to paranoia and notions like belief and action. I then go on to describe how people (especially professionals) employ certain rhetorical devices which establish im/plausibility and detail the influence of race, gender and class on this process. Finally I elucidate oppositions along which views about medication intersect and note some of the discursive effects of the organisation of talk about medication.

Finally, in the third part, I stand back from the study and focus on issues of reflexivity in the research and point towards specific implications arising from my analysis.


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... I had devoted the labour of my whole life, and had dedicated my intellect, blossoms and fruits, to the slow and elaborate toil of constructing one single work ... [which] ... was now lying locked up, as by frost, like any Spanish bridge or aqueduct, begun upon too great a scale for the resources of the architect; and, instead of surviving me as a monument of wishes at least, and aspirations, and a life of labour dedicated to the exaltation of human nature in that way in which God had best fitted me to promote so great an object, it was likely to stand a memorial to my children of hopes defeated, or battled efforts, of materials uselessly accumulated, of foundations laid that were never to support a superstructure, - of the grief and ruin of the architect.

de Quincey (1995, 1821) The Pleasures and Pains of Opium, p.36


Don Leopoldo's History of the Colonization of BelÚn has taken a decade or two more than ideally he would have wished. He convinces himself it is lacking only a final chapter (on the territoral dispute with Ecuador, with a commentary on Gregory XVI's Bull of 2 June 1843 recognizing Peru's right over the diocese of Soreto). Plus an index, of course.

He has given up hope that when complete it will immortalize his name and cause the jungle round to break out in psalms.

Shakespeare (1995) The Vision of Elena Silves, pp.5-6


ACKNOWLEDGEMENTS

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Over the time this thesis took to write a wide range of people inspired, supported, encouraged and influenced me. Six years is a long time to stay the course and so I am especially grateful for those who have stuck around from the start and been consistently encouraging through the many ups and downs. In this respect I do have to thank Ian Parker a great deal. He has commented on numerous drafts of chapters, put up with both procrastination and wild optimism and been extremely useful to kick ideas around with. I must also thank Sam Warner (who has been doing similar research for nearly ten years now) for her support. Miles Mandelson generously allowed me half a day a week for research for one year which enabled me to start this research. I am grateful to the then Mersey Regional Health Authority for giving me a grant (No. 670) which supported my research for two years. Eugenie Georgaca, and Terence McLaughlin together with other members of the Discourse Unit have also been very supportive. The librarians at Manchester Metropolitan University (especially Hugh) and at Whiston Hospital deserve mention for their patient processing of numerous Inter Library Loan requests. Various correspondents (both written and electronic) helped me keep ideas alive and developing: Jennifer Clegg, Philippa Garety, Julie Hepworth, Brendan Maher, Louis Sass, Carol Sherrard, David Smail and James Walkup.

A number of friends and relatives have been ever-ready with supplies of support and encouragement to live a more rounded life whilst putting up with PhD preoccupation and conversations routinely punctuated with 'of course, when I've finished the PhD...'. Some have also been handy at digging up numerous examples of paranoia in popular culture. Thanks to Andy Cullen, Dave Spellman, Julie Ross, Neil Forthergill, Karen Flockhart,

Allen Crocker, Denise Hogg, Andy Roberts, Martin Kelleher, Paul Manasse and Judith Chaloner and Agnes, Tony, Carol, Ryan, Laura and Michael Harper.

More specific thanks is due to those who commented on early drafts of chapters or on manuscripts submitted for publication which subsequently formed the basis for chapters 1-3. I am grateful for comments and suggestions to: Arthur Still and two anonymous referees (chapter 1); Jaan Valsiner and two anonymous referees (chapter 2); Hank Stam, Chris Eccleston and two anonymous referees (chapter 3); Mark Stowell-Smith (to whom I'm also grateful for more general discussions) and Dick Hallam (chapter 4); Derrol Palmer (chapter 5); Jennie Day, Jenny Evans, Tony Hak, Guy Holmes, Lucy Johnstone, Dave Pilgrim and Carla Willig (chapter 6). I am extremely grateful to Erica Burman and Richard Bentall who kindly read through an initial draft of the dissertation and gave me their comments.

A number of people at work provided help and encouragement. Thanks go to Barry Fitzgerald, Tricia Hagan, Rani Prasad and Rob Rosser and other members of the (now) Psychological Therapies Service, Community Mental Health Teams and the Continuing Support Team. Marilyn Maloney and Shelagh Parkinson typed forms and suchlike, often at short notice -- thanks. It is impossible to name all those who have been supportive, so to those I have not mentioned by name, my grateful thanks.

Finally, my thanks go to those users of psychiatric services and professionals who were willing to talk about their views and experiences. This thesis is dedicated to them.


CONTENTS

Acknowledgements

Abstract

Introduction p. 1

Part I: Examining the contexts of the concept of paranoia p.9

1.0 Histories of suspicion in a time of conspiracy: A reflection on Aubrey Lewis's history of paranoia p.12

1.1 Writing insanity's past: From grand to local histories p.12

1.2 Lewis (1970) as an exemplar of psychiatric histories of psychiatry p.15

1.3 'Paranoia and paranoid: A historical perspective' p.18

1.4 Re-reading Lewis: A critical overview p.20

1.4.1 Continuity p.21

1.4.2 Presentism p.24

1.5 Unspoken, silenced and subjugated stories in Lewis's history of paranoia p.26

1.5.1 The historical and philosophical context of paranoia p.27

1.5.2 The nosological context of paranoia p.29

1.5.3 Psychoanalytic views on paranoia p.30

1.5.4 Histories of conspiracy, suspicion and paranoia outside psychiatry p.32

1.5.5 Critical accounts of psychiatric history p.33

1.5.6 Autobiographical and non-pathological accounts of paranoia p.34

1.5.7 Reflexivity p.35

1.6 Back to the future or foward to the past? p.35

2.0 Paranoid positioning:

The discursive construction of paranoid and conspiratorial positions in popular culture p.37

2.1 Introduction p.37

2.2 Placing paranoia in its cultural context p.38

2.3 Theory/method p.40

2.4 The Prisoner and the panopticon: Panoptical culture as a condition of possibility for paranoia p.42

2.5 Paranoia and discursive variation p.44

2.6 The dualistic construction of paranoia p.46

2.6.1 Positioning the other as paranoid p.47

2.6.1.1 Rhetorical strategies for resisting the paranoid position p.51

2.6.2 Positioning the self as 'knowing' p.53

2.6.2.1 The rhetorical use of intentionality p.54

2.6.2.2 Subverting trust and optimism as a warrant for action p.55

2.6.2.3 Conspiratorial discourse as revelatory evangelism p.56

2.7 What's so funny about paranoia? Humour as a failed attempt to breach duality p.57

2.8 Reflexivity: Appropriating discourses of suspicion in interpretation p.60

2.9 The rhetorical effects of conspiratorial accounts p.63

3.0 Deconstructing 'paranoia': Towards a discursive understanding of apparently unwarranted suspicion p.65

3.1 Introduction p.65

3.2 Beyond the pathologizing of 'paranoia' p.65

3.3 Deconstruction and mental health p.67

3.4 Six oppositional presuppositions in traditional theorizing p.68

3.4.1 The individualization of suspicion p.69

3.4.2 The assumption of rationalism p.71

3.4.3 The pathologization of suspicion p.74

3.4.4 The reification of form over 'meaningless' content p.76

3.4.5 The notion of a pure pathological state p.78

3.4.6 The dominance of professional over popular, 'lay' and patient views p.81

3.5 Deconstruction, variation and contradiction p.83

3.6 The merits and possibilities of a discursive account p.85

Part II: Examining how paranoia is constructed through distress, diagnosis

and treatment in professional and service-user talk p.89

Preamble to interview analysis methodology p.91

A word or two about the use of extracts p.92

The study p.94

Initial plan p.94

Making contacts p.94

Approaching participants and seeking consent p.95

Interviewing users and contacting professionals p.95

Transcription p.97

Analysis p.97

4.0 Analytic theme I: The construction of the cluster of emotions, actions and beliefs associated with paranoia p.98

4.1 Introduction p.98

4.2 The social construction of emotion p.102

4.3 The construction of distress in paranoia p.107

4.3.1 Paranoia and moral accounting p.107

4.3.1.1 Moral positioning p.107

4.3.1.2 Paranoia as filling a lack and as needing to be controlled p.108

4.3.1.3 The functions of moral accounts p.109

4.3.1.4 Agency, ambiguity and contradictory imperatives p.110

4.3.1.5 Paranoia as personal trait/external medical condition p.110

4.3.1.6 Paranoia as a warrant for professional intervention p.111

4.3.2 Paranoia and moral accounting: paranoia as a self-description p.111

4.3.2.1 Paranoia as a way of being p.112

4.3.2.2 Paranoia as (obstructed) action p.112

4.3.2.3 The construction of distress through implicit comparisons p.112

4.3.2.4 Paranoid tautologies: diagnosis as explanation p.113

4.3.3 Delusions as external and powerful p.113

4.3.3.1 Delusions as powerful p.114

4.3.3.2 Delusions as external p.114

4.3.3.3 Constructing distress p.115

4.4 Deconstructing the causal link between paranoid thought/belief and emotional distress p.116

4.4.1 Beliefs, distress and rationality: the traditional view p.119

4.4.2 Critiquing the traditional view p.121

4.4.2.1 Asking impossible questions: The presence/absence of thoughts p.121

4.4.2.2 Not believing doesn't stop you believing p.122

4.4.2.3 The primacy of fear in arriving at a diagnosis as opposed to belief in diagnosis I p.123

4.4.2.4 The primacy of fear in arriving at a diagnosis as opposed to belief in diagnosis II: fear talk p.123

4.5 Deconstructing the causal link between paranoid thought/belief and action p.125

4.5.1 Reading 'action' as violence p.125

4.5.2 Linking paranoia and violence in the popular mind p.128

4.5.3 Action and embodiment: Violence, paranoia and masculinity p.130

4.5.4 Paranoia as an explanation for 'out of character' conduct p.132

4.5.4.1 Action as driven p.132

4.5.4.2 The dominant view and the closing down of discursive options p.134

4.5.4.3 Accepting the dominant view p.134

4.5.4.4 Paranoia and warranting action p.134

4.5.4.5 Variable agency p.134

4.5.5 Risk and potential action/violence p.135

4.5.5.1 The construction of risk and the implication of danger p.135

4.5.5.2 Risk and the linking of beliefs and actions p.136

4.5.5.3 The social effects of a discourse of risk p.136

4.5.5.4 Risk and the construction of subjectivity p.137

4.5.5.5 Risk and the recasting of professional obligations p.137

4.5.5.6 Risk and the construction of dramatic narratives p.137

4.5.6 Paranoid delusions, risk and texts of fear p.138

4.5.6.1 Marking Mike out as dangerous p.138

4.5.6.2 The development of a dramatic linear narrative p.139

4.5.6.3 'Agitation' and the hydraulic construction of distress p.140

4.5.6.4 Objectifying the subject p.140

4.6 Discussion p.140

5.0 Analytic theme II: The construction of the paranoid subject's beliefs as irrational, implausible and unwarranted p.142

5.1 Introduction p.142

5.2 The discursive construction of plausibility p.143

5.3 Some rhetorical strategies used in accomplishing im/plausiblity p.145

5.3.1 Metaphors of depth p.145

5.3.2 Checking with others p.146

5.3.3 Rhetorical innoculation p.147

5.3.3.1 'That might be reasonable, but not this ...' p.148

5.3.3.2 'It could be true, but ...' p.149

5.3.4 Appealing to other effects p.150

5.3.5 Simple assertion and category entitlements p.151

5.4 Deconstructing plausibility p.153

5.4.1 Reliability and rationality: the case of bizarre delusions and their implications for paranoia p.153

5.4.2 Paranoia and the vicissitudes of validity p.158

5.5 The unravelling of rationality p.159

5.5.1 The use of non-rational criteria p.159

5.5.2 Psychiatry's failed empiricism: the lack of empirical investigation in the judgement of plausibility p.163

5.5.3 Reflexivity and rationality p.168

5.5.4 Cultural assumptions about belief and fear p.170

5.5.4.1 Gender and the construction of plausible fear p.172

5.5.4.2 Race, culture and the judgement of plausibility p.177

5.5.4.3 Class and credibility p.183

5.5.5 Rationality isn't the whole story p.186

5.5.5.1 Delusions as meaningful p.186

5.5.5.2 Distress and rationality p.187

5.5.5.3 The grain of truth in delusions p.188

5.6 Judgements of plausibility and the management of users' identities p.189

5.6.1 The rationality trap p.190

5.6.2 The insight trap p.192

5.6.3 Plausibility and the accomplishment of oddness, bizarreness and implausibility p.198

5.6.3.1 Plausibility breakdowns and the breaching of cultural assumptions p.200

5.6.3.2 Insight and the service-user's awareness of the potential of plausibility breakdown p.203

5.7 Discussion p.204

6.0 Analytic theme III: The discursive construction of medication and other forms of professional intervention p.205

6.1 Introduction p.205

6.2 Discourse, medication and the body p.207

6.2.1 From medicine to meaning p.207

6.2.2 The move to meaning p.207

6.2.3 Stubborn materiality p.209

6.2.4 Towards a discursive reconciliation p.211

6.3 Tablet talk and depot discourse: rhetorical strategies in the concourse of medication discourse p.213

6.3.1 Some comments on rhetorical features and devices in medication talk p.214

6.3.2.1 Drug names p.215

6.3.2.2 Dosage and quantificatory rhetoric p.216

6.3.2.3 The use of Latin words for dosage information p.216

6.3.2.4 The conflation of professional intention and drug action: the construction of 'side effects' p.217

6.3.2.5 Maintenance, monitoring and the management of risk p.218

6.4 Oppositions and dilemmas in medication talk p.219

6.4.1 Medication works/doesn't work p.219

6.4.1.1 Medication works p.219

6.4.1.2 Medication doesn't work p.221

6.4.2 Medication is the only obvious treatment/ isn't the only thing p.223

6.4.2.1 Medication is the only obvious treatment p.223

6.4.2.2 Medication isn't the only thing p.225

6.4.3 Pharmaceutical faith and medical optimism/ pessimism about pills p.226

6.4.3.1 Pharmaceutical faith p.227

6.4.3.2 Pessimism about pills p.229

6.4.4 'Non-compliance' as not following medical advice/ as an assertion of agency and choice p.231

6.4.4.1 'Non-compliance' as not following medical advice p.231

6.4.4.2 'Non-compliance' as an assertion of service-user agency and choice p.233

6.4.5 Medication as targeted/ non-targeted and crude p.235

6.4.5.1 Medication as targeted p.236

6.4.5.2 Medication as non-targeted and crude p.237

6.4.6 Accounting for medication working/accounting for medication not working p.239

6.4.6.1 Accounting for medication working p.240

6.4.6.2 Accounting for medication not working p.241

6.4.6.2.1 'The patient is a non-responder' p.243

6.4.6.2.2 'There are obviously odd exceptions': rhetorical innoculation and qualification p.244

6.4.6.2.3 'We don't know' p.244

6.4.6.2.4 Because the patient is chronic p.246

6.4.6.2.5 Because the patient is on too low a dose p.247

6.4.6.2.6 Because the patient is on too high a dose p.249

6.4.6.2.7 Because the patient is on the wrong drug p.250

6.4.6.2.8 Because the patient is on too many different kinds of drugs p.251

6.4.6.2.9 Because the patient has not been compliant with their medication regime p.253

6.4.6.2.10 Because the patient has been wrongly diagnosed p.253

6.4.6.2.11 Because some of the patient's problems are due to manipulative behaviour p.255

6.4.6.2.12 Because it is just that the drugs are not working 'fully' p.256

6.4.7 Talking treatments are unnecessary compared to medication/Talking treatments are important p.257

6.4.7.1 Talking treatments are unnecessary compared to medication p.257

6.4.7.2 Talking treatments are important p.259

6.5 Constructing the objects and subjects of medication talk p.260

6.5.1 A middle-of-the-road position on talking treatments p.262

6.5.2 Multi-factorial talk and rhetorics of chronicity p.265

6.5.3 Symptom-talk, maintenance and relapse p.269

6.6 Discussion p.273

Part III: Reflecting on the research and its implications p.275

7.0 Reflecting on this account p.277

7.1 Introduction p.277

7.2 Reflecting on reflexivity p.278

7.3 Reflexivity as accountability and explication of context p.280

7.3.1 Interests and agendas, accounts and accountability p.281

7.3.2 Reflexivity and the practice of the research project p.284

7.3.2.1 Getting the research off the ground p.284

7.3.2.2 The practice of interviewing p.285

7.3.2.3 Reflexivity and transcription p.288

7.3.2.4 Reflexivity and analysis p.289

7.3.2.5 Reflexivity and the dilemmas of feeding back p.294

7.4 Reflexivity and the production of written accounts: interpretation and analysis as a writing practice p.296

7.5 On reality and utility: reflexivity and 'ontological gerrymandering' p.299

8.0 Implications for political interventions in mental health p.301

8.1 Implications and applicability: the very idea p.301

8.1.1 Problematising 'applicability': the case of clinical psychology p.302

8.1.2 Further problems with 'applicability': ethics and politics p.304

8.1.3 Even more problems with 'applicability': definitions and oppositions p.305

8.2 Theory/practice p.307

8.3 Practical implications for different interest groups p.310

8.3.1 Implications for the organisation and delivery of mental health services: from power to partnership? p.310

8.3.1.1 Abstract box. General and specific implications for workers in mental health services p.312

8.3.1.2 Interventive box. Suggestions for action by workers in mental health services p.313

8.3.2 Users of mental health services p.317

8.3.2.1 Abstract box. General and specific implications for users and ex-users of mental health services p.320

8.3.2.2 Interventive box. Suggestions for action by users and ex-users of mental health services p.320

8.3.3 Relatives, friends and carers of users p.322

8.3.3.1 Abstract box. General and specific implications for relatives, friends and carers p.322

8.3.3.2 Interventive box. Suggestions for action by relatives, friends and carers p.323

8.3.4 Psychotherapy and counselling practitioners p.323

8.3.4.1 The notion of therapy p.324

8.3.4.2 Cognitive-behaviour therapy p.325

8.3.4.3 Family-management/psycho-educational approaches p.326

8.3.4.4 Psychodynamic/counselling approaches p.328

8.3.4.5 Feminist approaches p.328

8.3.4.6 Therapy and community action p.330

8.3.4.7 Therapies in response to postmodernism and social constructionism p.330

8.3.4.7.1 Narrative Therapy p.331

8.3.4.7.2 Solution-focused brief therapy p.333

8.3.4.7.3 Andersen and Anderson & Goolishian: from questioning to listening and reflecting p.335

8.3.4.7.4 Just therapy and the notion of accountability p.336

8.3.4.8 Social constructionist/postmodernist therapies: A contradiction in terms? p.336

8.3.4.8.1 Individual/social p.338

8.3.4.8.2 Pathology/normality p.338

8.3.4.8.3 Reason/unreason p.338

8.3.4.8.4 Form/content p.339

8.3.4.8.5 Purity/messiness p.339

8.3.4.8.6 Professional/lay/user p.339

8.3.4.9 Abstract box. General and specific implications for therapists p.341

8.3.4.10 Interventive box. Suggestions for action by therapists p.342

8.3.5 Training and supervision of mental health professionals p.344

8.3.5.1 Abstract box. General and specific implications for trainers and supervisors p.345

8.3.5.2 Interventive box. Suggestions for action by trainers and supervisors p.346

8.3.6 Implications for academic researchers in psychiatry and allied disciplines p.347

8.3.6.1 Abstract box. General and specific implications for academics and researchers p.349

8.3.6.2 Interventive box. Suggestions for action by academics and researchers p.350

8.3.7 General political action p.351

8.3.7.1 Abstract box. General and specific implications for political activists p.354

8.3.7.2 Interventive box. Suggestions for action by political activists p.354

8.4 Discussion p.355

References p.357

Appendices p.439

1. Overview of criteria for evaluating qualitative research p.440

2. Letter to Consultant Psychiatrists informing them about the study p.443

3. Letter to service-users informing them about the study p.444

4. Consent form for service-users p.445

5. Guidelines for interviews with service-users p.446

6. Guidelines for interviews with psychiatrists and CPNS p.447

7. Guidelines for interviews with GPs p.448

8. Biographical and interview details p.449

9. Form for service-users to give consent to interview professionals p.450

10. Consent form for psychiatrists p.451

11. Consent form for GP/CPN p.452

12. List of interview combinations p.453

13. Transcription conventions p.454

14. Time taken to transcribe interviews p.455

15. Steps taken in discourse analysis p.456

16. Questions used in analytic reading p.462

17. Broad inclusive categories used at start of analysis of interview material p.463

18. Broad inclusive categories aiding in the development of discourses of plausibility p.464

19. Broad inclusive categories aiding in the development of the concourse of medication discourse p.465

Figure

Figure 2.7: Cartoon p.58


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