Deconstructing Paranoia: An Analysis of the Discourses Associated with the Concept of Paranoid Delusion

David J. Harper PhD Thesis June 1999

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Chapter 5

Analytic theme II:

The construction of the paranoid subject's beliefs as

irrational, implausible and unwarranted

I live in New York. I had to move there for health reasons: I'm very paranoid and New York is the only place my fears are justified.

Anita Wise (Just for Laughs, Channel 4 TV, 1993)

5.1 INTRODUCTION

In chapter 4 we examined how notions of belief, distress and action were constructed in the professional literature and in the interviews. In this chapter I want to take a step back from the 'delusional belief' per se and examine the processes by which a belief comes to be seen as delusional. By 'seen', I am not simply referring to an individual diagnostic decision but in a much wider sense including how cultural beliefs come to be constructed as delusional. In chapter 3 I developed a deconstructive reading of paranoia and noted how particular oppositions were involved in its construction. In this chapter I will explore how decisions about whether beliefs are delusional are made and we will see how a number of these oppositions and other cultural assumptions are manifested in those decisions. Elsewhere I have critiqued the assumptions of definitions of delusions (Harper, 1992) and looked at some of the rhetorical strategies used in defining delusions (Harper, 1991, 1994b). Here, however, I will argue that the central judgement in deciding whether a belief is delusional is its plausibility. I will then note some of the rhetorical strategies used by professionals and users in the interviews to mark out certain beliefs as implausible. Second I will draw on similar extracts to show how such judgements of plausibility are constructed and that they rely on certain taken-for-granted assumptions. I will then go on to demonstrate how, when these assumptions are examined, the obviousness of plausibility judgements unravels. I will argue that assumptions about rationality are used to judge the plausibility of beliefs, but that they break down especially when attempting to judge the plausibility of fears. Such a deconstruction of plausibility and of rationality leads us to look again at how the 'oddness' of people's beliefs is accomplished and we will discuss some of the implications this has for the management of users' identities.

5.2 THE DISCURSIVE CONSTRUCTION OF PLAUSIBILITY

In this chapter I will not be analysing definitions of delusion in depth. As in the previous chapter, I am not so much interested in essentialist propositions about what a delusion really 'is', but rather how the decision that something is a delusion is accomplished in language. In other words, how do people come to say that something is a delusion? What reasons do they give? What do they say they look for(1)? I will be looking at how a 'belief' is marked out both as separate and as deviant. From this perspective, the particular criteria used in making such decisions can be seen not simply as na´vely objective criteria 'out there' to point to in making a decision, but rather as rhetorical resources which are drawn on to construct accounts of beliefs as implausible. Although there are accounts within the professional literature which might seek to discriminate terms like 'bizarreness' and 'plausibility' on technical grounds I will be taking a different approach. As in the previous chapter, since my aim is to look at how the concept of delusion is actually used in practice, I will be focusing less on a priori distinctions between such terms but more on their rhetorical effects. In Chapter 4 we saw how a number of terms and concepts clustered around paranoid delusions and it is likely that the same is true of judgements about delusions. One might expect to find reality, plausibility, bizarreness and truth in such a cluster. I will argue that the contents of this cluster have a similar rhetorical effect, that of marking out certain views as deviant (cf Heise, 1988). I would argue that it is the deviancy of a belief that is regarded by psychiatry as most important since the common aim of most definitions of delusions is to mark out certain beliefs as separate (Harper, 1994b). Thus Moor & Tucker ask 'what criteria should we use in identifying delusions' (1979, p.388) illustrating the imperative to mark out such beliefs and clearly presupposing the existence of a class of things called delusions (cf Harper, 1992).

Heise (1988) argues that judgements about whether beliefs are delusions are intrinsically social. Rather than beliefs being judged against an assumed objective comparison, Heise foregrounds the fact that judgements are made by people in particular contexts which are rule-governed. Thus, he suggests that 'delusions are a form of cognitive deviance' (Heise, 1988, p.267) and a violation of the 'rules of what one is expected to believe and not believe, to take as true and as false' (Douglas & Waksler, 1982, cited in Heise, 1988, p.267).

These rules are of course linked to institutional power, and the professional hearer of statements uttered in a psychiatric context has the power to infer a belief from such statements and to decide on its plausibility. Professional judgements are transformed into hypothetical constructs (eg symptoms or disease processes) which then obscure the integral role of the judgement process. Fernando notes:

in the process of making a diagnosis, judgements are hypothesized as symptoms and illnesses -- as 'things' that exist in some way separately from the people who make the judgements and from the people ('patients') who are said to 'have' them. In such a system, the permeation of racist and other undesirable perceptions is almost inevitable unless very careful measures are taken to counteract them.

Fernando (1997, p.16)

The importance of the professional's judgement in decisions about plausibility is minimised and obscured in diagnostic manuals but is recognised by some of the leading commentators in the field of delusion research. Thus, as we saw in chapter 3, Maher (1992) has argued that beliefs are diagnosed as delusional and false simply because they are deemed implausible with little or no investigation of their truth status.

5.3 SOME RHETORICAL STRATEGIES USED IN ACCOMPLISHING IM/PLAUSIBLITY

Edwards (1991) has argued that current work on categorization has been dominated by cognitive models so far and has proposed a discursive approach. He has suggested that categories are 'adaptable to the situated requirements of description' (p.523). Such a view is supported by recent empirical work like that of Barrett (1988), and Soyland (1994b) which has illustrated how one kind of categorization practice, that is diagnosis, is accomplished through language and, far from being na´vely objective is a complex and flexible process. Of course, such findings are not new and both Ingleby (1982) and Coulter (1979) have noted the pragmatics of diagnosis. Thus Coulter notes that 'above all, psychiatric diagnoses are devices for pragmatic use in ward or treatment allocation' (1979, p.149).

Elsewhere (Harper, 1994b) I have shown how mental health professionals vary in the accounts they give of diagnosis between those which are 'empiricist' (ie stressing objectivity and science) and those which are 'contingent' (ie stressing subjectivity and personal investment). Both these accounts are mobilised in discussions with professionals who use a number of discursive strategies to meet challenges to diagnostic criteria.

In this study my analytic focus, developed from this position, was more on the rhetorical strategies which appreared to be used by both professionals and users to mark out certain beliefs as implausible and delusional or as plausible and credible. Because of restrictions of space here I will be giving brief examples of such strategies with relatively little analysis. Such strategies included the use of metaphors of depth, checking with others, rhetorical innoculation, appealing to other effects, simple assertion and the use of category entitlements.

5.3.1 Metaphors of depth

Dave: I mean I suppose that's the thing isn't it? I mean what, what makes it <Terry: Yeah> a delusion rather than a/ <Terry: /Well/> /rather than like a, a kind of very strong, extreme opinion.

Terry: Yeah, that's right. I think, when you first sit down, you don't really get a great deal erm <coughs> I think to, to elicit, you know erm information about or to get more information about the delusions you have to be prepared to spend a great deal of time with these people. <Dave: Uh-huh> 'Cause often, you know, like for a short interview or up to half an hour, you know, they can, they can sort of cover these things up quite well or it doesn't affect them in day-to-day living anyway. But, you know, if you start asking questions about erm erm specifics <Dave: Uh-huh> you know, related to, to the delusion well you can often get, you know, really quite deep into it, you know.

Terry Reid (CPN)

In this extract the notion of a metaphor of surface/depth is drawn on (line 120) to explain how delusions can appear absent when really they are present. This is achieved by suggesting that a delusion may not be apparent even if it does not appear to affect the user (line 117) or if it is being 'covered up' (line 117). Thus Terry is able to account for the apparent variability in the presence of delusions: it is only when you engage in detailed enquiry, when you go 'deep into it' with a user that it is possible to see the delusion. This strategy could also be used to account for why a belief which at first sight seems plausible turns out not to be so after further enquiry. However, the importance of judgement and interpretation is played down in this kind of account: delusions are seen as being elicited, implying that they emerge as if of their own accord by virtue of the questions asked and time spent with the user and without any relationship with the nature of the interaction between the speakers. The delusion is thus constructed as an entity that is recognizable as such and this helps to make it appear that the influence of professional judgement is minimal.

5.3.2 Checking with others

A second strategy for achieving implausibility, draws on a consensual view of reality. Here, the plausibility of an account was judged by the extent to which others agreed with it. Once again, the role of judgement was made to appear minimal in such accounts as were the potential problems with such an approach (such as the objections that relatives might not have enough evidence or that they might have their own agenda).

Dave: So what usually would, would tell you that something was more real? Would it be when say there was another relative accompanying them who was saying how they think [inaudible]/

Dr Cornwell: /Well the first thing I would do is to ask anybody else that's there, you know "What is the set-up with Mrs Smith?". <Dave: Uh-huh> "Is this just something that's" <Dave: Uh-huh> "has some basis of fact in it? Or, or is it his pure imagination?" [Inaudible sentence]

Dr Cornwell (GP)

This extract gives a simple example of this strategy. Of course, this was used not only by professionals but was one which users were encouraged to employ. Indeed, reality-testing by checking out one's version of events with others might also be part of a user's coping strategy.

Dave: /Right <pause>. Have you always felt that sometimes it's not true or is that just something that, that you've kind of thought of recently?

Sharon: Erm well I'm starting to think now that it's not true 'cos I go round with my family, go around town or whatever, and they'll say 'well I didn't hear her say that' <Dave: Uh-huh>. So <pause> then I know that I'm probably imagining it or expecting it <pause> <Dave: Uh-huh>.

Sharon Harrison (Service-user)

5.3.3 Rhetorical innoculation

Sorenson (1991) describes how texts may include devices which serve as rhetorical innoculations -- that is, by incorporating a potential challenge and neutralising it they therefore defend an account against further challenges -- cf Barthes' (1957) study of myth. In decisions about delusions, one potential challenge that users could make in their defence, for example, is to argue that their beliefs are reasonable or true. Here, I will give examples of two kinds of rhetorical innoculations. The first draws on a notion of there being a threshold or boundary of normality which deluded beliefs cross, while the second raised the possibility of the truth of beliefs in order to question their likelihood.

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

Dave: Right, well <pause> thanks for the taking the time out. We should only be about ten or fifteen minutes, okay. Erm, I mean just, just first of all I was interested in erm if you could remember what it was that er first prompted you to <Dr Chapman: Uh-huh> refer Mr Sullivan to the psychiatrist. <Pause> If you can remember that.

Dr Chapman: <Pause> [Examines notes] I remember he came to see me in 1988 originally and he was a member of the local [name of political party] and he originally was saying there was a lot of problems with the [name of political party] in [name of local town] and erm he felt he was being followed by members of [name of a faction] and the secret service. <Dave: Right> Very complicated thing. Just before Mrs Thatcher got in and when politics were very hairy <Dave: Uh-huh> and I thought it was quite reasonable. I believed him at that, at that stage erm. <Pause> And then his wife came to see me saying he was much, he was having delusions that he was being a part of the secret, the IRA and the secret service, I think, at that, that stage. <Dave: Uh-huh> And MI5 were following him and he was very restless. He was spending his time walking round [name of local town], walking round parks and things. And it was her that prompted me to erm <pause> referring him. [Inaudible] admitted under Section <pause> <Dave: Uh-huh> of the Mental Health Act. This was early <pause> early 1987.

Dr Chapman (GP)

In this extract, the notion of there being a stage at which a belief was once considered reasonable is used. Thus at lines 11-12 Dr Chapman notes that he saw Mike Sullivan's beliefs as reasonable. Later, it is implied that, following further information from Mike's wife, Dr Chapman saw the beliefs as less reasonable. By stating he was willing to believe Mike's account at first, Dr Chapman is positioned as open-minded and reasonable, thus innoculating any potential objections that Mike was not given a fair hearing. The additional information he reports from Mike's wife is not that dissimilar from what Mike had already told him apart from the IRA and his restlessness. The report of Mike's wife's concern works to suggest that the previous information needs to be seen in a new light. Once again, the role of the professional's judgement is minimised here. Rather, the implication is that a belief may start out as reasonable and then become delusional almost of its own accord. Other speakers talked of beliefs crossing thresholds of some kind. Thus Dr Smith talked of beliefs 'going beyond the bounds of normality' (lines 213-214), whilst John Stewart described his beliefs as being 'blown out of all proportion' (line 40). Of course, professionals might well vary in their estimations of the likelihood of various events -- Dr Chapman's willingness to accept the likelihood of political intrigues might position him as more liberal than other medical colleagues. Ingleby (1982) notes:

understanding someone is simply not possible without crediting them with a basic degree of plausibility. And the more charitably inclined we are to someone, the more likely we will be to see their actions as 'making sense'; in this way, judgements about intelligibility are inextricably linked to moral attitudes.

Ingleby (1982, p.133)

We will return to this issue at different points throughout this chapter.

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

A related rhetorical strategy focused not so much on whether beliefs were considered to have crossed a threshold of reasonableness but more on the likelihood of a belief being true.

Dave: Are there particular, are there particular things that you would look for to judge whether a belief is, is delusional erm and, and whether it's er paranoid or persecutory, you know to mark it as different from another, from a normal belief?

Dr James: <Pause> Er yes. Er generally it is erm, we have to <pause> we go by his erm, you know, social background, educational as well as er his intelligence, you know, that those things are also important erm in judging these. But we first er ask the simple questions "Do you feel people are talking about you? Laughing er at you? Or laughing behind your back" and we ask, or he will answer "Why do you?" [inaudible] happens and then he will, might give er further details, then go onto clarify what he mean by that. Then er whether people are actually, they could, they could be, you know, it does happen erm <pause> er the doubt comes where people some have come, you know, some say "Oh the [inaudible] have indicated that I smell", you know, which could be true, sometimes the body odour is there. Erm the difference in how they tell then how, you know, then we, these are doubtful areas <Dave: Right> we have to go into further details. But some of them are very very clear that er that they are, [inaudible] look back and there is nothing there, you know and they, he shouted at me, it's not there and he goes into a bus-stand or a strange, you know, areas where he, unfriendly places er again people are looking at him, staring at him. I think that is erm wrong. Then the doubt becomes more <Dave: Uh-huh> er then you would [inaudible] probably it is er a primary delusion er then clarify a bit more. Erm right erm.

Dr James (Consultant Psychiatrist)

A possible challenge to a judgement of delusion is that the beliefs are true. In this extract, the possibility of beliefs being true is acknowledged at lines 19 and 21 and addressed. This account is structured to anticipate and deal with such challenges and is reminiscent of those noted by Harper (1994b) where, even if one challenge is effective (eg that a belief is true) another criterion is then drawn on. Thus at line 22, Dr James notes the importance not only of truth as a criterion but 'how they tell then how' (ie there is reference to the thought process behind a belief). The role of the professional's judgement is obscured here. Instead, the notion of doubt as agentive is introduced. Dr James talks of 'the doubt comes where...' (lines 19-20) and 'the doubt becomes more' (line 28). Such an account constructs doubt as an effect of the potentially delusional belief rather than a property of the professional's own judging activity.

A rhetorical strategy noted earlier, of delusions being revealed through enquiry with the user are drawn on here. Thus Dr James talks of going 'into further details' (line 23) and of the need to 'clarify' with the user (lines 18 and 29) -- there were examples of the use of this strategy in other interviews.

5.3.4 Appealing to other effects

At other points, it was not so much the belief itself that professionals focused on, but the perceived consequences of the belief.

Dr Smith: No Ive only looked into the case-notes. In the recent past erm he over and over er again has complained about gangs, gangs er talking about him and trying to intimidate him. Er thats his fear, sort of fear of gangs. Erm, there again, in real-life, yes it is possible that you have er sort of gangs [Tape beeps] in your neighbourhood and they try and intimidate you but <pause> you need to look at it affects his life so much [Tape beeps] that he cant function.

Dr Smith (Consultant Psychiatrist)

In this extract, the notion that emotions should be somehow proportional to a belief is drawn on. Thus whilst the possibility that there might be 'gangs' is accepted, the extent to which Paul Dench is affected by his fear is commented on. This is another example of rhetorical innoculation. The effect of a belief on the user's life was another example of a supplementary diagnostic criterion which, whilst not forming part of the formal definition of a delusion, could be drawn on when one criterion (eg the truth of a belief) was challengeable (cf Harper, 1994b).

5.3.5 Simple assertion and category entitlements

A final rhetorical strategy which appeared in the interviews involved the simple assertion that a belief was plausible or implausible. Such assertions appeared to gain their authority from the use of a category entitlement -- a rhetorical device used to indicate that certain people in certain positions know certain things (Edwards & Potter, 1992). Thus a psychiatrist might be expected to know whether a belief is delusional whilst an ordinary person might be expected to know what they have seen, and so on.

Dave: Right, right, okay. <Pause> Wh-, when you were talking with him how, I mean we were talking just in the kitchen before about believability, I suppose Im wondering erm <pause> what is it, what is it about it that makes you feel that its unbelievable erm and, and also did you actually check any of the, the, the things that Alan said in any way?

Dr Lloyd: <Pause> Uh its inherently unbelievable <Dave: Right> the World Health Organization isnt interested in Alan Roberts, certainly wouldnt have been interested in him when he was five, promising him a load of money, certainly wouldnt have been sh-, I mean it just doesnt <Dave: Uh-huh> make <Dave: Uh-huh> any logical sense. <Pause> Alan was absolutely convinced, ab-, absolutely convinced. It didnt matter how many people said "Look Alan this just doesnt make any sense. Its not inherently logical, it, <Dave: Uh-huh, uh-huh> the World Health Organization doesnt function like this" all of those sorts of comments, he just said "Well you have your view and Ive got mine and I know Im right. And it came down to "Well we know were right". <Dave: Right> And that was it. Erm <pause> no we didnt check.

Dr Lloyd (Consultant Psychiatrist)

In this extract, Dr Lloyd simply asserts that Alan Roberts's belief is 'inherently unbelievable' (line 143), indeed he follows this line of belief to the point where he acknowledges that there was no checking of the belief. Once again the role of professional judgement is minimised by constructing believability as a property of Alan's belief -- it is seen as inherently unbelievable. Moreover, notions of logic are drawn on (line 149) although in a formal sense the belief would not necessarily be seen as illogical. Such statements gain their authority through category entitlement -- Dr Lloyd might reasonably be expected to know what is delusional or not. Alan also draws on assertion and category entitlement, but with different consequences.

Dave: But you don't doubt that it all happened in this kind of way?

Alan: No, I know for a fact that it happened like that.

Alan Roberts (Service-user)

In this extract Alan asserts that he knows 'for a fact' that his belief is true. Once again, this is a simple assertion and, once again, it draws its authority from category entitlement -- one would assume an ordinary person would know what had happened to them. However, these strategies have different effects depending, as Heise (1988) notes, on the social power of the speaker. In this case, Alan has less power than Dr Lloyd, and so he becomes positioned as not willing to question his beliefs and thus as deluded. Such rhetorical strategies can be found elsewhere in discussions about paranoia, and often assertion and category entitlement can be linked with the use of extreme case examples (Edwards & Potter, 1992). Thus Dr Robert Butler (an Assistant Attending Psychologist) comments:

It is one thing to interview a patient who believes the CIA is following him and another to evaluate a patient who believes that electrodes have been implanted in his testicles by the CIA. This later belief, to me, is more definitively delusional, especially when there clearly are no electrodes in existence and the patient steafastly holds to his beliefs independent of all irrefutable evidence to the contrary.

Butler (1993)

In these extracts I have illustrated some of the rhetorical strategies employed to construct certain views as plausible and others as implausible. We have also seen how plausibility is a flexible, pragmatic and discursively negotiated act and not a na´vely objective judgement.

5.4 DECONSTRUCTING PLAUSIBILITY

Plausibility is a relatively untheorised concept but one that is, as we have seen, central in judging beliefs as delusions. For psychiatric judgements to have the status of science there obviously need to be clear and consistent guidelines on judgements of delusions. However, the literature is filled with variability in terms of the consistency of those judgements and even in terms of the definition of delusion. Two of the criteria which are used to determine the usefulness of psychiatric categories are reliability and validity. How does the notion of plausibility bear up in relation to these criteria?

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

Although psychiatric definitions of delusion assume the existence of an independent existing reality, there is also an assumption of inter-subjective consensus in the interpretation of that reality. In other words, psychiatric manuals and texts presume that if someone holds an implausible belief then this will not be shared by others and will be equally-well recognised by all as a delusion. However, there is no clear agreement on what constitutes implausibility.

There are relatively few studies of the reliability of diagnoses of delusions. One well-known project was the World Health Organization's International Pilot Study of Schizophrenia (World Health Organization, 1973). This was a study of 1202 psychiatric patients from nine centres in different countries. They reported that the intra-centre reliability of diagnosis of delusions (of all categories) varied from R = 0.83 to R = 0.98 whilst the inter-centre reliability was R = 0.61. The suggestion was made that the lower inter-centre reliability was due to the different methods used. Space does not permit a detailed methodological analysis here however a few points can be made. Firstly, the numbers of patients were quite small (less than 150 in each centre) and delusions were only found in a proportion of these -- an average of 3.8% of patients scored on one of the 13 units of analysis relating to delusions (World Health Organization, 1979). As a result numbers for comparison were small and only the first interview in each month was used for reliability purposes whilst only 21 interviews were used in the inter-centre reliability studies limiting numbers even further. Furthermore, reliability ratings can be affected by the numbers of items involved and the numbers of items relating to delusions were the highest. Given the small numbers of subjects, reliabilities of codings of sub-categories of delusions would be uninterpretable. Moreover, reliability can be affected by the choice of statistical method (Harrop et al., 1989). Another issue is that raters (especially those in intra-centre ratings) also had the possibility of discussing their respective findings before deciding on a diagnosis. Thus the measure is of whether raters can come to an agreement rather than whether something can be reliably immediately recognised. A final problem is that studies like this do not face psychiatrists with those not in contact with psychiatric services but who might have 'odd' views -- thus the ratings do not tell if the professionals can agree on what discriminates a delusion from other odd beliefs. The situation had changed little by the two year follow-up study when interviews were conducted with 813 of the original 1202 patients where delusions were one of the groups of units of analysis with the lowest inter-centre reliability.

Some of these issues can be seen more clearly if we take 'bizarre'(2) delusions as an example, Flaum et al (1991) noted 'a significant amount of confusion and disagreement in the interpretation of the term 'bizarre' among ourselves and our colleagues' (p.59). As a result, they conducted a study estimating the inter-rater reliability of judgements of the bizarreness of a sample of delusions(3) as consistently low (kappas of below 0.4) regardless of whether a structured definition was given. Goldman et al (1992) achieved a kappa coefficient of 0.78 but this study used only three raters and discrepancies between ratings were 'resolved through discussion until a consensus judgement was obtained' (pp.495-496). It could be argued that reliability studies only reveal ideological agreement; they do not attest to the fact that something is bizarre, merely that raters can agree amongst themselves that something is bizarre. Thus reliability ratings measure the extent to which cultural assumptions about what constitutes bizarre are shared. Moreover, the fact that raters are allowed to discuss disagreements, resolve them and then enter the newly agreed ratings as data for a reliability analysis seems to stretch the idea of reliability too far. Spitzer et al, (1993) noted that Goldman et al's high ratings were also affected by the fact that the three raters had 'participated in weekly discussions of ratings of psychiatric symptoms, including bizarre delusions, for a year and a half before the study' (1993, p.883)! Kirk & Kutchins (1992) have noted a number of methodological problems with reliability ratings (for example the use of 'weighted' kappas) including the fact that one would expect a proportion of ratings to coincide by chance.

Other studies have continued to report low reliabilities despite attempts to increase reliabilities with new definitions of bizarre delusions. Spitzer et al (1993), for example, tried different definitions of bizarre delusions, finding kappa coefficients of 0.64-0.65. They had clearly hoped that providing more precise definitions would increase reliability but they did not find this -- despite there being a homogeneous group of raters (Mojtabai & Nicholson, 1995). They then argued that the 'fair' reliabilities they had found were comparable to those of other psychiatric clinical categories. They noted, for instance, that reliability ratings of persecutory delusions in the multisite field trial of the Structured Clinical Interview for DSM-IIIR, resulted in a kappa of 0.54. Mojtabai & Nicholson (1995) conducted a further reliability study, attempting to avoid what they regarded as methodological flaws in previous studies. Their reliability coefficients (gathered from ratings made by 50 psychiatrists from a random sample of 180 psychiatrists in the American Psychiatric Association) ranged from a kappa of 0.38 to 0.43 for different definitions. They concluded that given the low reliability and unproven utility, bizarre delusions should not be given special weight as a criterion in diagnosing schizophrenia. Eisen et al. (1998), in their assessment of the Brown Assessment of Beliefs Scale, dropped an item evaluating plausibility and bizarreness because of its low inter-rater reliability and correlation with the overall score. Garety & Hemsley (1994), in a study involving comparing the scores of three raters, found mean weighted kappas of 0.31 for the bizarreness of delusions and 0.40 for inherent implausibility. They noted that those categorised as paranoid had lower implausibility and bizarreness ratings than those categorised as schizophrenic.

The difficulty with reliability clearly poses a problem for empirical psychiatry since, by its own canons, the criteria for determining bizarre delusions are not reliable. The fact that criteria are not used consistently causes some problems for psychiatry. It responds to these in a number of ways: by calling for stricter definitions (Spitzer et al, 1993; Mojtabai & Nicholson, 1995) or by claiming comparability with other diagnostic concepts (Spitzer et al, 1993). Comparable problems with the concept of delusion itself have led to similar moves. Thus the difficulties in coming to a satisfying definition led Oltmanns (1988) to list a number of features not all of which are necessary to term a belief delusional. Other suggested solutions have included: arguing that there are commonalities in delusion definitions (Butler & Braff, 1991); having broader, more flexible definitions (McAllister-Williams, 1997); and, finally, by arguing for more precise definitions (Spitzer, 1995)(4). Recently there have been moves to change the emphasis in delusion definitions away from a concern with truth and understandability because of the considerable conceptual, philosophical and empirical problems encountered. Suggested responses have included shifting the emphasis to: a concern with the distress caused by beliefs (Chadwick et al, 1996); assumed differences from the way normal people acquire beliefs (Gillett, 1995); and the way people convey and change beliefs through language (Palmer, 1997a; Spitzer, 1990).

The difficulties psychiatry experiences in finding a consistent and scientific basis to mark out certain beliefs as implausible could be seen as marking the presence of an opposition noted in chapter 3: that of the purity/messiness of diagnoses. Rather than such variability in agreement being a problem, however, I wish to argue that it is the very flexibility of definition that allows diagnostic criteria to be used in a wide variety of circumstances. Of course, where there is agreement this may say more about the sharing of cultural assumptions of what constitutes implausibility and, in Ingleby's (1982) words, how charitably inclined to the other we are. There is some evidence to suggest that, for example, psychiatrists tend to concur with police officers' judgements of mental illness in some of the people they arrest (Rogers, 1993). This would suggest that one basis for diagnostic decisions is not so much the highly technical psychiatric proficiency of the hearer but, rather, the fact that there may be shared cultural assumptions about what constitutes oddness -- ie the implausibility or bizarreness of what they say or how they act. There are potential flaws in such an argument. First, the judgement of oddness by the 'ordinary person' might be neither wholly reliable nor valid -- for example we do not know if the police fail to diagnose some who might be seen as mentally ill by psychiatrists. Given the difficulties in reliability and validity of psychiatric judgements it is likely that ordinary people's judgements will be highly variable too. Second, even if 'ordinary people' were able to agree on what was odd, there is a level when there is such a lack of specificity in what is so regarded that the judgement becomes banal -- for example Gleeson (1991) noted that lay people did not distinguish between mental illness and learning disability.

Much of the interest in the literature is on the reliability of ratings but another canon of the utility of diagnostic criteria is that they must be valid. It could be argued that delusions fail this test too.

5.4.2 Paranoia and the vicissitudes of validity

Studies of reliability often conflate reliability with validity. Thus Boyle notes:

I have noticed a decline in discussion of the issue of validity in the DSM and other psychiatric literature. Instead there is a preoccupation with reliability, which is not the essence; I suspect that this distraction is not accidental.

(1996/7, p. 19)

There is much conceptual confusion in the psychiatric literature. Thus Spitzer (1990) argues that the definition of delusion 'should always be a matter of fact' (p.396), as if it were simply an empirical matter. His approach to definition is to begin with the clinical use of delusions, that is with the situation where 'clinicians want to refer to some phenomena as delusions' (p.378, emphasis added). He goes on to delineate what delusions are from the assumption that such clinical desires are unproblematic. Much psychiatric research follows this same pattern as Boyle (1994) has described: there is an assumption of irrationality, and criteria are then laid out to essentialise this irrationality. However, the focus of the defining gaze is on the psychiatric subject, not on the interaction which produces the decision of irrationality.

Parker et al (1995) describe a similar pattern in research on thought disorder. They note that a characteristic of such studies is the 'complete suppression of the context of the interaction' (p.99). In other words, as Swartz (1994) has stated, 'a text cannot be said to be simply incoherent; it is incoherent to a particular listener in a specific situation (p.32). The same is true of diagnoses of delusions: a person's views cannot be simply regarded as delusional -- they must be regarded as such by a particular person in a particular situation. This fact becomes even more important when we see how variable that judgement can be from person to person, and problems of reliability testify to this. Plausibility is not an essential quality of a belief -- it is a quality of the interaction between speaker and hearer as Ingleby (1982) has noted. Foress Bennett (1997) comments:

the plausibility of a story in itself is a function of its hearer's readiness to make sense of its organization at multiple levels: the plausibility of narrative relies on the symbiotic relation of text organization (schemas) and cultural assumptions about the way the world works.

(1997, p.100)

In other words, to be plausible, stories need to match certain cultural and narrative expectations. Foress Bennett notes an important distinction between the plausibility of an account and the credibility of the story-teller.

5.5 THE UNRAVELLING OF RATIONALITY

In this section I turn the analytic gaze away from the delusional paranoid subject and towards the diagnoser. What are the cultural assumptions of diagnosers? What are the narrative expectations which apparently delusional accounts fail to meet? What is the relationship between the plausibility of an account, the credibility of the account-giver and the hearer's 'readiness to make sense'? Here we can note the way non-rational criteria are employed, the lack of empirical verification of the falsity of supposedly delusional beliefs, the way in which reflexive application of theories of delusion to psychiatry's own theories is warded off and the role of cultural assumptions about fear and belief and gender, race and class.

5.5.1 The use of non-rational criteria

In chapter 3 I noted contradictions present in psychiatry's presupposition of rationality. Similar inconsistencies were encountered in the interviews. In the following extracts we can see that the judgement about beliefs being delusional is not solely based on the belief itself but there are also a wide variety of non-rational influences: socio-cultural background; education; intelligence; history of mental health problems; employment; and being a 'good member of society'. These influences seem to suggest that beliefs may be interpreted according to social status norms, revealing cultural assumptions about how these norms influence a speaker's credibility.

Dr Smith: /Right, erm <pause> what we need to understand is whether this belief erm erm <Dave: Sorry, can you be careful of the table, theres the mike <inaudible>> yeah, right erm is in keeping with his sort of erm socio-cultural background. Thats what, thats what we need to understand.

Dr Smith (Consultant Psychiatrist)

In this extract Dr Smith introduces the notion that the normality of beliefs cannot solely be determined on the basis of the belief in some abstract sense, but also involve judgements about context, especially about culture -- such assumptions are present in the DSM-IV definition of delusion. Harper (1992) has noted that there are difficulties in deciding what the appropriate cultural comparisons are in such situations and he has suggested that the use of the term 'culture' in this context, because of its ambiguity, can help 'avoid the accusation of cultural insensivity whilst still trying to characterize particular beliefs as abnormal' (p. 363).

Dr James: <Pause> Er yes. Er generally it is erm, we have to <pause> we go by his erm, you know, social background, educational as well as er his intelligence, you know, that those things are also important erm in judging these.

Dr James (Consultant Psychiatrist)

In this extract, Dr James draws on a wider notion of context through the use of the term 'social background' which is taken here to include educational background and intelligence. Thus there appear to be a wide range of factors which might be felt to affect the normality of a belief. These criteria might allow a belief considered normal for someone of a certain intellectual status to be considered abnormal for someone of a different status. Note that these factors would not necessarily affect the truth status of a belief, rather they affect the way in which a belief is heard.

[Dr Chapman:]Most people, patients we see with paranoia have always had a history of mental illness <Dave: Right> and we tend to take, not always take what they say seriously or as truth <Dave: Right> and you can ask questions to question their beliefs and their paranoia. <Dave: Right> But when you've someone presenting for the first time who's up to now has been completely rational, and they're in a good job and a member of s-, a good member of society as it were <Dave: Uh-huh> they come along with slightly strange ideas it's very difficult to know whether it's true or not.

Dr Chapman (GP)

Here we see that other criteria may influence decisions about whether a belief is delusional: previous history of mental illness (line 36); previous rationality (lines 39-40); employment status (line 40); being a 'good member of society' (line 40). The use of such criteria might enable diagnosers to hear two people with the same belief but different life circumstances very differently. Thus certain people would not be taken seriously (line 37). Further, judgements were also influenced, as we saw earlier, by the views of families:

[Dr Howard:] and then I got a phone call from her dad <Dave: Right> and that changed things. He told me what she was like at home <Dave: Right> said that she was really quite bad, she thought the radio was talking about her and all this and causing a lot of trouble at home <Dave: Right> and he thought she was, as I say, showing a lot of, more signs of paranoia than I picked up.

Dave: Right and you said that you felt she was paranoid but it, but what was it kind of normal everyday kind of paranoia/

Dr Howard: /She was well, [inaudible] it could have been justified/ but she, I didn't really know what was really going on. I'd been hearing it from the family that she was being, like not just as bad as she was saying. She was saying that she had to give up work because they were talking about her, talking behind her back <Dave: Right> being very nasty to her. And then she got the stage when she'd go out to the nightclubs and socially with her sister <Dave: Uh-huh> and then she couldn't do that because they were talking about her when she went out <Dave: Right, right> which could have been justified I suppose, you know, a bit of an exaggeration perhaps <Dave: Uh-huh> but when you hear the family, how the family said she was <Dave: Right> it was more totally unjustified.

Dr Howard (GP)

Dr Howard notes how the phone call from Sharon Harrison's father 'changed things' (line 17) and that beliefs which previously might have been seen as 'justified' (line 31) were not when 'you hear the family' (lines 32-33).

Cultural assumptions could be seen not only in the use of criteria other than objective and rationalist ones but also in speakers' beliefs about the likelihood of events like infidelity. Of course, professionals' beliefs about the currency of certain beliefs may well be wrong -- I noted in chapter 3 that survey results show that quite high numbers of the general population say they believe in a variety of supernatural phenomena (Social Surveys/Gallup Poll Ltd, 1995).

Dave: Right, right, right. And er I mean, do you have other people who tell you that er they think their wives are being unfaithful and you think there's probably some truth to that?

Dr Cornwell: Most of them. <Laughs> Most of them that [inaudible word] their wives are being unfaithful are quite right. <Dave: Right, right, so/> /And they don't, when I say they don't get upset about it er this chap was, was totally over the top <Dave: Right> er as far as I was concerned.

Dr Cornwell (GP)

In this extract, Dr Cornwell notes how he believes most reports he hears of infidelity. However, he contrasts this with John Stewart's report. Rhetorical innoculation features here with the speaker presenting himself as open to the possibility of infidelity but then justifying why he does not think it was correct in this case. The criteria used here reflected the emotional effect of the belief, that it was 'totally over the top'. Thus not only the veracity of beliefs, but also their emotional consequences invite certain narrative and cultural expectations about what most people in a similar situation would do.

The use of non-rational criteria, as we have seen, implies that diagnostic judgements are influenced by certain cultural assumptions (eg about social status). Another issue that undermined the dominant positivist, rationalist and empiricist story of diagnosis was the apparent failure of diagnosers to follow the scientific investigative method implied by the literature on delusions.

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

Definitions of delusion commonly make reference to such beliefs being false and the need to compare beliefs with 'external reality' as it is assumed normal people do. Moor & Tucker go so far as to suggest that a belief can only be regarded as delusional if the believer has been presented with 'considerable evidence against the belief' (1979, p.391). However, as we noted in chapter 3, 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, p.261). He notes that it is not 'customary to present counterevidence to the patient; it is not even common to present vigorous counterargument' (1992, p.261). Here then, we begin to see how psychiatry, whilst 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 judgements on the basis of common-sense and taken-for-granted social assumptions. Such a situation creates the context for some of the 'truth games' that circulate in discussions about paranoia, for example Maher's (1988) 'Martha Mitchell effect'. A good example of such an effect is in one of the interviews from Harper (1991):

[Beardsley:] Um I've got another example of, you know, a girl who came grossly disordered who insisted um that she uh had a major modelling job on. And no-one believed her: she was in a right state, she was in no physical state to model and sure enough a couple of days later her face is all over the back of bus shelters. And she in fact had done a big national, modelled for a big national poster campaign.

Dr Beardsley (Consultant Psychiatrist [INT5, p.10])

The existence of such cases could be seen as creating dilemmas for diagnosers since they suggest that users are often diagnosed without an empirical investigation of 'external reality'. The question then arises on what basis can beliefs be considered delusional and not in accordance with external reality? Questioning professionals about whether delusions were ever empirically investigated provided an opportunity to see how this dilemma was resolved.

Dave: Right. Do you usually try and see if there's any evidence for it. I mean do, how much would you kind of look into it?

Terry: Well in the Beattie situation, we did look into it. I mean he was, he was seen by a number of, of professionals and it was reviewed. <Dave: Uh-huh> Erm <pause> the issue about erm <pause> <laughs> I can, I can see your point, you know, I mean, the particular footballer involved was John Barnes. Now nobody actually went up to John Barnes <Dave: Right> and said er "Have you got a contract out on <Dave: Right> so-and-so for three hundred thousand pounds?". Erm I don't know that they ever met or <Dave: Right> or anything like that. Erm so no we don't always investigate that, you know, not to that level.

Terry Reid (CPN)

Here, the speaker notes that professionals did 'look into' a supposed delusion but this appears to reflect an interview of Mr Beattie rather than an investigation elsewhere. No further investigation was conducted and this presents a dilemma for him. This appears to be resolved through three rhetorical strategies. The first is the implication that the investigation of John Barnes is somehow unreasonable and an assumption that there would be no connection between Beattie and Barnes. This is achieved by constructing the idea of an investigation as comic by using an extreme example: of 'going up to' John Barnes and asking him if he had a contract on someone (line 43). By making this suggestion and the notion of Barnes and Beattie being connected ('I don't know that they ever met' [line 45] which of course is not the same as saying 'I know they never met') seem silly, the speaker is thus relieved of the need to give empirical reasons for why an investigation was not appropriate.

A second strategy is the introduction of the notion of levels of investigation (line 46) which implies that there was an investigation to a certain level. Finally, the notion that investigations 'don't always' occur (line 46) normalises this.

[Terry:] But, you know, if you start asking questions about erm erm specifics <Dave: Uh-huh> you know, related to, to the delusion well you can often get, you know, really quite deep into it, you know. <Dave: Uh-huh> Erm it doesn't always help, you know, you have to see whether there's actually a source to it. Er some of them appear so bizarre that erm <pause> you know, I think, I think we just take it for granted sometimes <laughs> that er <Dave: Uh-huh> you know, that it is a delusion <Dave: Uh-huh> erm. And whether resources would stretch to investigate every one of them, you know <Dave: Right> it's a er, and whether that can be justified I don't know.

Terry Reid (CPN)

In this extract, Terry acknowledges that delusions at times are not investigated because they 'appear so bizarre' (line 122) and that professionals 'just take it for granted' (line 123) that the belief is delusional. This again shows the influence of assumptions about the likelihood that a belief is true. The potential challenge about such a lack of investigation is met with two strategies: first noting that resources are an important factor and, secondly, that not 'every one' of all such beliefs should be investigated. It is implied here that an initial judgement is made to decide whether there is a prima facie case of the need for an investigation.

Dave: I mean do you do, do much checking on things or do you usually go from a kind of rule of thumbabout how plausible it is er that somebody, how plausible somebody's belief is.

Edward: I do, yeah, I tend to sort of <pause> almost make a fairly quick judgement I suppose in terms of it being a delusional belief but I do check round anyway more, more in terms of actually getting more detail about how that affects the person. <Dave: From the person?> Yeah.

Edward Jackson (CPN)

Here the notion of an initial 'quick' judgement (lines 40-41) is drawn on again. Here, the defence against a possible challenge is that Edward did 'check around' (line 41). This is similar to the strategy in an earlier extract from Terry where the notion of levels of investigation was drawn on to support investigation through further discussion with the service-user. Here checking refers to further information from the service-user (ie how the belief affects them). The use of the word 'check' is interesting in this respect. I introduce it in my question in terms of 'checking on things' but it is an ambiguous term and it could mean (i) checking as in investigating the evidence for a claim, (ii) checking as in further discussion with the person, or (iii) checking for further symptoms. Its ambiguity enables Edward to refer to 'checking' without addressing the claim that this case might warrant a thorough investigation.

Dave: Did you check any of the details that you thought he was kind of mis-, misattribut-, misattributing things about, like the <pause> Ma-Gic character or any of the other characters mentioned?

Dr Lloyd: Uh here I have to make a confession. I told Alan that I was going to contact Ma-Gic and he gave me some bizarre tale about her <Dave: Right> where I might find her and in fairness I did make <pause> a couple of phone calls but it was utterly impossible to track the woman down <Dave: Right> because she doesnt exist <Dave: Right>. Erm <pause> but I told Alan that I had and that was wrong, I shouldnt have done that. And the reason I told him I did was because I promised him that I would <Dave: Right> erm and I hadnt been able to and what I should have said is I didnt do it. Erm but I actually told him that I did and that I hadnt been able to get any useful information from her erm and part of that was a deliberate ploy to, to say "Look weve gone to the source. <Dave: Uh-huh, uh-huh> Its a load of rubbish. Now what have you got to say" <Dave: Uh-huh> and his answer was "Its true". <Dave: Uh-huh> <Pause> His belief system is utterly unshakeable.

Dr Lloyd (Consultant Psychiatrist)

Here, Dr Lloyd acknowledges that a thorough investigation was not carried out although it is argued that this was because the evidence did not exist. This raises the issue of how to prove a negative with potentially unverifiable beliefs. Moreover, the question is also raised about what would constitute a thorough investigation since here Dr Lloyd notes that he made 'a couple of phone calls' (line 159) but later implies he did not consider this a thorough investigation. Elsewhere in the interview he stated more unambiguously that he did not investigate the evidence when he said 'no we didn't check' (line 153).

It is implied that Dr Lloyd had already decided the belief was unlikely to be true: 'he gave me some bizarre tale about her' (line 158) and the investigation ended after only 'a couple of phone calls' (line 159). Despite the apparent ambiguity about the evidence (ie the difficulty of proving a negative -- that the Ma-Gic character didn't exist) his account of what he said to Alan is quite unambiguous 'it's a load of rubbish' (line 167). This implies that professionals can draw on a repertoire in which they make confident statements where there may actually be less than solid grounds for confidence and this could be seen as a use of the category entitlement rhetorical strategy. By contrast, ironically, Alan is more consistently empiricist:

Dave: Right, right. What, you know, what would you erm, what would you suggest yourself would be the way of helping somebody who kind of had the same kind of difficulties as you had?

Alan: Well, if it's to do with a lot of money I would want to know who the people are <Dave: Uh-huh> and ask them if it's true or not. <Dave: Uh-huh> Mr, Dr Lloyd er <pause> made the assumption that I was suffering from delusions before he tried to contact any of these people.

Alan Roberts (Service-user)

Dave: Right. I, I just wondering, you know, before, we were talking about people who are diagnosed by doctors as, as having delusions er and I asked you what was the best way to help them just in your opinion what, what would your advice be to the people themselves who had those diagnoses what, what would, you know, what kind of advice would you give to them?

Alan: Well if they can, the things should be verified shouldn't it? <Dave: Uh-huh> I mean, it might be true. <Dave: Right. So they should try and get evidence to support what they're saying?> I think that the ball lies with the people investigating them, like the doctors. They should find out from the people who he claims is involved. <Pause> <Dave: Uh-huh> It'd save a lot of trouble then, wouldn't it?

Alan Roberts (Service-user)

In both these extracts, Alan draws on the notion that it is possible to unproblematically apprehend truth through empirical methods. Thus he uses terms like 'true' (line 193) 'verify' (line 395), 'evidence' (line 397) and 'investigation' (line 398). This allows Alan to position himself as open-minded and there is thus a strong challenge to psychiatry: 'the ball lies with ... the doctors' (lines 397-398). Then, even if it has been investigated and been found not to be true Alan can still criticise the methods used or challenge the investigators by claiming they have simply made 'an assumption' (line 194) that he is deluded. Of course, Alan's statement of empiricism is heard differently because of his position as deluded and as a service-user in that Dr Lloyd might consider this as further evidence that his 'belief system is utterly unshakeable' (Dr Lloyd, line 169).

From the extracts we have so far examined it would be hard to escape the conclusion that, at least some of the time, professionals do evidence certain cultural assumptions which are taken-for-granted and constructed as so obvious they do not even merit comment. It could be argued that psychiatry fails to live up to the standards it sets itself. Most striking however, is the failure to apply standards and diagnoses reflexively.

5.5.3 Reflexivity and rationality

It has become a standing joke in much of the literature on delusions that scientists themselves can operate in a delusional manner, that despite having evidence presented to them apparently contradicting their findings they still continue to hold to those theories. Thus, at the end of their book, Garety & Hemsley (1994) comment:

In writing this monograph, we have noted in ourselves a tendency to selecting information consistent with our hypotheses and ignoring disconfirmatory evidence, which is similar to those processes we have suggested as relevant to delusions. We hope that in this case, this insight prevented the process becoming pathological and that the evidential support that we provide proves convincing to the reader.

Garety & Hemsley (1994, p.142)

This statement is the last in the book and is mentioned in passing and with some irony. But what are we to make of this? Does this not affect the findings and interpretation of the rest of the work? Such a comment raises significant questions for the pursuit of empirical research in psychiatry. For example, what might some of the consequences be if scientific research is not purely rational?

The ironic title of Boyle's (1990) book (Schizophrenia: A Scientific Delusion?) highlighted a central argument that the psychiatric literature on schizophrenia had 'delusional' characteristics in that the schizophrenia hypothesis continued to be used despite apparent contradictory scientific evidence in terms of reliability and validity. Critics, like Bentall, et al (1988), Boyle (1990, 1994) and Pilgrim (1988), who have pointed to the lack of reliability and validity of the schizophrenia concept, have been forced to find non-rational (ie more social and political) reasons for the continuation of certain concepts in psychiatry. Such attempts point to both a rationalist and non-rationalist discourse in psychiatry. In chapter 3 we commented on how psychiatry's relationship with rationality was ambivalent and that there were a number of points at which rationality broke down within psychiatry. Objective empirical psychiatry's inability to use its theories reflexively (ie to apply them consistently and internally) is another example of a breakdown of rationality.

The existence of both rationalist and non-rationalist discourses has been discussed elsewhere (eg Harper, 1994b) but of additional interest here is the humour that arises out of the application of psychiatric and psychological processes to the practice of those disciplines themselves -- my (Harper, 1995a) discussion of 'meta-paranoia' (the paranoia of paranoia researchers) is an illustration of this. We saw in chapter 2 how humour often indicates the clash of two incongruous discourses. However, humour may also be used as a rhetorical strategy by reducing reflexivity to a joke and thus deflecting a potentially serious challenge to empirical psychiatry.

Of course, another area where psychiatry lacks some reflexivity is in its view of reasoning processes. Thus a great deal of the literature focuses on the supposedly abnormal reasoning processes of those considered to be deluded but very little on either the reasoning processes of psychiatrists or of supposedly 'normal' people. Thus, David (1994) notes that 'human reasoning is far from perfect. Though it is rule-based, our adopted rules bear little relation to formal logic' (p.238). This is said quite unself-consciously, but where does this leave the supposedly logical and rational processes of diagnosis? Moreover, we know from the work of, for example, Nisbett & Ross (1980) that 'normal' reasoning can exhibit many biases.

There have been no extracts from the interviews here largely because reflexivity was not an issue discussed in the interviews although there were examples in Harper (1991). However, reflexivity has been raised here because it seems another point at which rationality unravels. Of course the very absence of discussion of reflexivity in the interviews may be indicative in itself. The meaning of absence more generally will be discussed later in this chapter. What is also absent here is some discussion of reflexivity issues in this account -- for reasons of convenience I have devoted chapter 7 to discussion of this.

We have, so far, explored a number of the ways in which rationality is not a sole determining factor in the diagnosis of delusions. Foress Bennet (1997) pointed to the importance of cultural and narrative expectations in judgements of plausibility. There were a number of ways in which cultural assumptions were manifested in the interviews. In the next section I will take three aspects of embodiment to illustrate how paranoia is multiply constituted and that assumptions about gender, race and class mean that paranoia can be constructed and read differently.

5.5.4 Cultural assumptions about belief and fear

What are some of the cultural assumptions and narrative expectations about beliefs and fear which are present in definitions of delusions? Spitzer suggests that 'a delusion is a delusion not because it is false but because it is a statement made in an inappropriate context, and most importantly, with inappropriate justification' (1995, p.325). Such definitions clearly imply the importance of certain assumptions and Spitzer makes some of those assumptions explicit, thus 'normal people can give reasons, can engage in a dialogue and can engage in the possibilities of doubt etcetera, especially if we talk critically to them' (1995, p.325). He states this unproblematically whilst acknowledging that investigations about how 'ordinary' people change their belief systems in comparison with 'delusional' people is an area of empirical research that has 'hardly been undertaken so far' (p. 392)(5).

In chapter 3 we noted some oppositional assumptions in the concept of paranoia: individual/social; rationality/irrationality; pathology/normality; form/content; purity/messiness; professional/lay. The absent standard was that of the Western unitary rational subject. But as some have suggested, this subject has other characteristics too. Thus Boyle (1996) has noted how rationality has functioned to maintain gender and race distinctions whilst Warner (1996) has commented on how, within the legal arena, reasonableness is judged by comparison with the 'reasonable man'. Moreover, the very notion of rationality as disembodied and computer-like is a gendered one (Wilson, 1996). Thus judgements of plausibility and rationality could be seen to import a variety of assumptions about gender, race, age and so on. One of the areas where this comes into sharpest focus is in judging the reasonableness and plausibility of fears. Simpson (1996) notes that the difference between ordinary fears and those considered unusual (eg paranoia) is the extent to which fears are socially warranted. Hollway & Jefferson (1997), commenting on work on the fear of crime discuss the apparent paradox that those least likely to be victims of crime (ie older people) are actually the most fearful(6). They note that much of the fear of crime literature undertheorises the concept of fear and incorporates an assumption of the rationally calculating individual who objectively assesses statistical risk and whose fear mirrors this assessment. The absent standard of the unitary rational subject is omnipresent in considering the plausibility of fears and beliefs and in the next section, we will see how assumptions about plausibility are influenced by assumptions about gender, race and class. I will address these aspects separately here in order to examine each in detail although one must be careful not to become too organised by such pragmatic division(7).

5.5.4.1 Gender and the construction of plausible fear

Rienzi & Scrams (1991) give some illustration of how there might be different narrative expectations of men and women. In their study they asked male and female university students to assign gender to six descriptions of DSM-IIIR personality disorders. They reported that men tended to be diagnosed as paranoid, anti-social and compulsive whilst women tended to receive diagnoses of histrionic and dependent personality disorders. They argued on the basis of their study that this occured because these diagnoses mapped onto gender-specific role expectations and stereotypes. Thus within society in general, men are 'directed to be clever and aggressive but not antisocial, to be sophisticated and suspicious but not paranoid' (Rienzi & Scrams, 1991, p.978). One could conclude that paranoia might be a position allocated to those men who over-step the masculine stereotype. We noted in chapter 4 how paranoid violence tended to be seen as male by default and that where violence seen as paranoid involved women, gender tended to be presenced. It is, then, also a position in which women can be placed. Williams et al. (1981), for example, describe the diagnosis and treatment of 'the paranoid wife syndrome' which clearly operates as a policing of suspicion in heterosexual marital relationships. Neither DSM-IV nor Kendler (1982) note demographic differences in the diagnosis of delusional disorder although Blazer et al. (1996) note a slight relationship between gender and paranoia, with women reporting more paranoid symptoms, in their sample of people aged 65 and over. Thus rather than being straightforwardly gendered to the extent that there would be different prevalence rates for men and women it would perhaps be more accurate to say that the category of paranoia and associated fears signify differently for men and women and this will, of course, be influenced by other issues like class, race, age and so on.

Westwood (1990) is quoted by Edley & Wetherell (1995) discussing black men's negotiation of the dangers of city street-life. It was recognised by the men that the city centre was dangerous, that it

was not 'safe', in fact it was known to be hostile. The language of safety expresses the feelings of trust and being at home only in their part of town. 'Safe' also applied to people, those who could be trusted, and to situations where the men felt at home

Westwood (1990) in Edley & Wetherell (1995, p.113)

Such negotiation, whilst touching on issues of trust and safety, is cast (at least in the heading of the box in which Edley & Wetherell use the quote) as an issue of being 'streetwise' and is thus positively valorised -- in other words suspicion here is seen as plausible and warranted. However, compare this to a quote from a woman visiting a launderette in the evening:

I became terrified. I wanted to leave and find a laundromat that was busier, but my clothes were well into the wash-cycle, and besides, I felt I was being 'silly', 'paranoid'.

Sheffield in Kourany et al. (1992) quoted in Edley & Wetherell (1995, p.188)

Here, the same issues are not seen as being streetwise but rather as being paranoid. Of course I am not arguing that men may never say they are paranoid, rather, that it may have a different discursive force when said by a woman. For Sheffield, for example, paranoia acts as a restraint on action she might take to feel safer -- in other words her fears are felt as implausible and unwarranted. In this sense, both the possibility of the charge of paranoia and suspicion/fear act as a mechanism for policing women (Edley & Wetherell, 1995) and certainly empirical research suggests that women are more afraid than men of victimization, especially of sexual assault (Ferraro, 1996).

In their investigation of the rationality of fears of crime Hollway & Jefferson (1997) argue that such fears cannot be judged in terms of rationality, suggesting instead the need to develop theories which place anxiety at the centre rather than rationality. A look at the official statistics, however, would give one grounds to develop a 'rational' account of fear of crime for both men and women(8).

Ussher (1991) concurs with such a view commenting that:

On a daily basis many women feel that their very person is under attack, that they must continuously watch for their safety, that their sexuality is under constant surveillance. And this experience of surveillance is not based on paranoia.

Ussher (1991, p.265)

Such accounts suggest that women's fears are not implausible but also note the danger that those fears may be read as paranoid -- evidenced here through the use of the 'resisting the paranoid position' rhetorical strategy which we discussed in chapter 2.

The interviews by Westwood were with black men and this of course adds a further dimension since one might expect that any group seen as outside of or other to the white male mainstream might be positioned as paranoid if they are seen as unreasonably mistrustful -- where reasonableness is judged according to the canons of that mainstream. That mainstream of course, also positions those not defined as middle class and heterosexual as other too. This paranoid positioning is likely to be even more the case when marginalised groups comment on discrimination. Thus radical feminists, for example, might be termed paranoid or as having a 'chip on their shoulder' when commenting on patriarchal oppression. The same is likely to be true for considerations around sexuality. As with most mainstream psychiatric research where homosexuality is either pathologised or ignored, in the area of paranoia it appears to be ignored. It is likely that lesbians and gay men will be labelled as paranoid for perfectly legitimate suspicion, especially when commenting on their own victimization since psychiatry and psychology operate not only patriarchally but also heteropatriarchally (Kitzinger & Perkins, 1993; Perkins & Repper, 1996).

Thus judgements about the legitimacy of fears involve a whole range of cultural assumptions and these are gendered (although, of course, we cannot separate out the issue of gender from other issues like race and sexuality). In this extract we will explore how these gendered assumptions work in practice.

Dr Smith: Hes erm a martial art coach <Dave: Uh-huh> erm er hes over er six feet tall and probably weighs now sixteen stone but erm every time you see him er he says "I cant, I cant go on like this. Im terrified of the gangs".

Dave: Uh-huh. <Pause> And you feel that thats quite implausible because of his, kind of physical presence?

Dr Smith: <Pause> Erm I have visited his home. <Dave: Uh-huh> I havent seen any gangs. <Dave: Right> I must have been to his house at least three times. I havent come across any gangs. <Dave: Right> I havent seen any.

Dr Smith (Consultant Psychiatrist)

Here Dr Smith notes Paul's role as a martial arts coach and also mentions his size and weight, contrasting this with his fears of attacks by gangs (lines 477-479). The implicatory force of Dr Smith's remarks is that for these reasons Paul's fears are unwarranted. In my response I try to make this force more explicit by asking Dr Smith if he feels the fears are implausible because of Paul's 'kind of physical presence' (line 481). Rather than being a direct answer to this, Dr Smith's response implies the implausibility of Paul's beliefs through the introduction of another element: an appeal to his own experience and observation of Paul's home noting that he has seen no evidence of gangs (lines 482-484) -- an example of a category entitlement. Interestingly Dr Smith's comment implies there are no gangs through the use of the phrase 'I must have been to his house three times' although it stops short of saying there are no gangs and, if challenged, Dr Smith could say he was simply reporting what he had (not) seen.

In relation to gender this extract has a number of interesting features. First, is the use of size, weight and participation in martial arts as factors weighing against fear. In the previous chapter we discussed how size could be linked with gender to suggest the implausibility of men's fears. Although gender is not discussed overtly, one wonders whether a large woman would have been considered paranoid because of her size given the discourses available to position women as feminine and thus vulnerable. Secondly, Paul's claim (line 479) may have a different discursive force because he is a man -- that is, it may be heard differently for a man than a woman. There appears to be an assumption that Paul should not be afraid. What is not being said here, that could be said? Certainly Paul's vulnerability and fear are marked here, implying that Paul is weak. But Paul's masculinity is also invoked implicitly here with the effect that he is constructed as a weak man. A woman might be seen differently, although I am not claiming that she would then be constructed as rational, rather such a statement might still be seen as irrational but located differently in the web of discourses of insanity and feminity within which women are positioned. Whilst gender is not mentioned explicitly here by Dr Smith, Paul clearly at times constructs himself as positioned in relation to dominant masculine discourses about the expression of feelings so he clearly experiences this positioning in the wider culture. In his interview he notes that, as a man 'you can't cry and you ... can't show feelings' (Paul Dench, lines 188-189). Thus discourses of masculinity work not only to position men as more violent as we saw in the previous chapter, but also to position fearful men as irrational and weak.

5.5.4.2 Race, culture and the judgement of plausibility

Of course, assumptions about fear and rationality are not only gendered but, as we noted above, are also influenced by race and culture. All of the service-users interviewed in the present study here were white and British-born although some of the professionals were not. With regards to the professionals, their biographical details may be less important than the hegemonic effects of psychiatric discourse. Commentators have noted that as it is heteropatriarchal so also is it racist and colonialist (Fernando, 1993, 1997). The absent standard of the unitary rational subject is not only gendered but also raced and cultured. Gaines, for example, suggests that:

the various Western psychiatric sciences habitually construct certain Western selves (male, adult, Euro-American, or European Protestant) as rational and others as irrational and prone to delusions or other mental dysfunctions.

Gaines (1995, p.281)

Perkins & Repper (1996) comment that 'the social world in which all social groups must live is one that is defined by white, heterosexual men' (p.164). In the present study, one could explore some of these issues by examining how cultural considerations might influence the construction of paranoia and how white identities inform the texts and positions produced in relation to paranoia. For example, what is the relationship between certain accounts of paranoia and race? Moreover how might the construction of emotions be influenced by cultural assumptions? Alternatively, we might explore how considerations of culture are absenced through culture being seen as 'out there' or irrelevant for white British-born people -- ie those Gaines identifies as the cultural absent standard(9). Indeed, we might learn more about the cultural contours of paranoia by looking at what is implied in discussions about it or by what is not said rather than by what is made explicit.

Kendler's (1982) review of demographic studies reported that patients diagnosed as 'paranoid' were more likely to be immigrants (ie foreign born in Kendler's definition) than either 'schizophrenics' or those with 'affective illness'. Westermeyer (1989) in his paper on Hmong refugees and Ritsner & Ponizovsky (1998) in their study about Russian immigrants in Israel noted high prevalence rates of paranoid symptoms. Thus there clearly are racial and cultural influences on diagnoses of paranoia. What might this signify? One approach to this question is to suggest that this represents some form of pathology which may be further influenced by clinician bias or cultural differences in presentation (Whaley, 1997); another approach would argue that this may well reflect the result of well-founded fears of persecution in an immigrant's home country (Aron, 1988); a related approach would argue some forms of paranoia are 'rational' in a racist environment. Thus Blazer et al. (1996) have noted that for black people 'paranoid symptoms may represent an appropriate response to a hostile environment' (p.74). Certainly, official statistics on crime against black people in the UK would support the plausibility of such fears(10)

Devalda (1996) highlights this when she states 'as I lived in a white area people stared and I grew up paranoid and lonely' (p.5). She goes on to say,

The doctors have labelled me as a 'PARANOID SCHIZOPHRENIC'. I don't accept the label. I must admit that I am confused and even 'paranoid' in some all-white company. Basically racism is a white problem...If I am sitting in a pub amongst all whites, I am aware they are staring and possibly making sly remarks. It is not imagination or paranoia. Far from it -- it is stark reality.

Devalda (1996, p.5)

In chapter 2 we noted how conspiracy theories were likely to be used by powerless groups and reported Waters' (1997) analysis that conspiracies have occured in the past against black people. Similar comments have been made by J.L. White:

Part of the objective condition of black people in this society is that of a paranoid condition. There is, and has been, unwarranted, systematic persecution and exploitation of black people as a group ... White psychiatrists and psychologists often have considerable difficulty working constructively with the hostility and suspiciousness of black patients. This is because their frame of reference tells them that excessive suspiciousness is psychologically unhealthy.

J.L. White (1991, p.12)

Comments such as these have led some workers to argue, as Newhill (1990) has, that:

'healthy cultural paranoia' as an adaptive mechanism for coping with a life that is plagued by prejudice and discrimination must be differentiated from paranoia as a functional illness.

Newhill (1990, p.177)

Moreover, the American Psychological Association has recognised that 'healthy paranoia' may be a recognizable response to discrimination (American Psychological Association, 1993).

What do we learn about the cultural construction of paranoia from these accounts of 'healthy paranoia'? For a start, the implication is that unless we explicitly foreground discrimination that we run the risk of categorising others as paranoid unfairly. The implication is that ordinarily we compare the Other against an absent standard who has not experienced discrimination. Those who experience prejudice and discrimination are seen as unusual and exceptional cases. Moreover, it assumes that culture and race are grounds for foregrounding prejudice and discrimination although other forms (eg class, gender, sexuality and so on) are not automatically considered. Thus the absent standard against whom we compare the paranoid person is an individual without culture or race but who is unused to discrimination. This would imply that, given the extent of discrimination against black people (and, for that matter, women, gay men and lesbians, working class and older people) the absent standard is white (and male, heterosexual, middle class and younger). This raises the question of how reasonable it is to be paranoid if one is black and who has the power to decide this. Thus the plausibility of black and non-Western people's fears may be judged according to an inappropriate standard.

Boyle (1997a) presents another twist here when she notes that attention to the cultural context of beliefs is increasingly recognised as important for those from non-Western cultures but that this analysis has not 'amounted to any real change in the way we think about "delusions" and "hallucinations" in dominant western groups' (p.13). Rather, there is a homogenizing of culture -- it is seen as a case of geographical origin, language and/or skin colour. Thus white British-born people are somehow seen as 'the same'. This is far from the case of course. Perkins & Repper (1996) comment that people (including those from the West) do not belong to just one community, rather we belong to many: geographical, religious, political, sexual, philosophical and so on. Kingdon & Turkington (1994) note how there is 'a greater diversity of culture within western and other societies than often seems to be acknowledged in a mental health context' and that these are 'not determined by a separate language or skin colour' (p.23). They go on to note unusual beliefs in Western societies including belief in paranormal phenomena and aspects of youth culture. So the absent standard may incorporate cultural assumptions that are inappropriate for many of those in Western societies too. Indeed, the main agenda of such a process of comparison seems to be one of policing idiosyncracy.

But how are we to judge the plausibility of idiosyncratic beliefs and fears? In his discussion of the cultural context of delusions, Gaines (1995) reminds us of the difficulty of such a task by describing some of the variety of Western beliefs and practices some of which might seem bizarre to others including: Catholic nuns' vows as a form of 'spirit marriage'; miracles in Ohio; somatic beliefs in the Southern US; spirit-channeling; multiple personalities; delusions of specialness in inadequate US men; and Western persecutory beliefs (eg persecution by the CIA, FBI and so on).

Whilst there is some acknowledgement that for ethnic minorities a diagnosis of paranoia may be inappropriate it is noticeable that culture and race come to stand for issues relating to 'ethnic minorities'. Race increasingly becomes an individualised and abstracted issue of colour, culture and 'prejudice' rather than of structurally located power like institutionalised racism -- thus Westermeyer (1989) sees the development of paranoia as a failure by some Hmong refugees to 'acculturate' to the 'mainstream' rather than a failure by the mainstream to welcome them and embrace cultural diversity. This leads to two effects. First, the institutional relations of power which support and privilege the problematising of 'ethnic minorities' and the absencing of discussions of white privilege and dominance are not themselves problematised or seen as influential in the diagnosis of paranoia or in the development of subject positions seen by others as paranoid. Second, 'whiteness' is seen as homogeneous. Bhavnani & Phoenix (1994) and Wong (1994) have noted how these difficulties are common in the psychological literature on race.

How might we incorporate these concerns into the present study? Such an analysis has proven difficult here since I rarely raised these issues explicitly in the interviews. Rather this analysis will follow the theme of absence and implication highlighted earlier. One occasion where some of these issues were discussed explicitly, in my interview with Dr Smith, provides an opportunity to examine this in more detail, however.

Dr Smith: <Pause> Well quite often there is some degree of suspiciousness about our neighbours in any way er and if you have sort of unpleasant neighbours then probably your level of anxiety rises. Erm <pause> erm <pause> I cant really tell you any more than that.

Dave: Uh-huh. Did you think it might be a cultural thing that so many people <pause> focus on neighbours as a source of suspicion?

Dr Smith: Erm <pause> I cant, although Im seeing it here, my, my er, although I had some exposure to psychiatry, I didnt take job in psychiatry er in [name of foreign city], my psychiatric experience <pause> wholly er in the UK so its is, it is wholly sort of Western erm erm sort of psychiatric experience. Erm although occasionally I have seen patients at special request on my visit to [name of foreign city] I wouldnt be able to really answer that because I havent got sort of broader experience erm from, from another culture, I wouldnt be able to answer that.

Dr Smith (Consultant Psychiatrist)

In this extract Dr Smith talks of the limitation of his experience in other countries which prevents him from commenting on the influence of local culture (lines 571-573). Thus it is implied that 'culture' stands for that which is other, foreign and exotic and is not of use in uderstanding 'us'. Culture is also seen as a site of potential misunderstanding and this implies that if there are difficulties it is because of culture rather than because of, say, racism (racism is not mentioned in either this extract or, indeed, the whole interview by either of us). It is also implied that cultural influences might only be detected by comparing cultures (lines 575-576) -- this draws on a notion of culture as homogeneous and minimises the potential for within-culture differences and thus obscures the difficulties of how cultural comparison groups could be selected for those considered abnormal.

A major effect of this extract is to absence discussion of structures of institutional power which might have a direct bearing on the judgement of plausibility. Indeed, at other points in the interview Dr Smith talks of the over-representation of some ethnic minorities in psychiatric diagnoses but it is implied that this is due to cultural misunderstanding rather than racism -- this is a common effect of the Transcultural Psychiatry discourses which circulate in contemporary psychiatry (Parker, et al., 1995).

Within this account other issues are absenced. Thus the influence of whiteness, white identities and Western culture/s on the construction of paranoia as a social category, as a subject position and as a diagnostic category are all hidden although as I have argued in earlier chapters its historical emergence and contemporary employment is intimately linked to issues of culture. Discourses of paranoia, then, serve to position black people and immigrants as paranoid but present this as an issue of disembodied 'culture' with the implication that what is required is more understanding at an individual level (thus culture is individualized), rather than as an issue of power where the implication might be to effect a change in the distribution of power at a social and political level. Moreover, with 'culture' being seen as to do with explaining alien culture, the influence of culture both in the development of certain beliefs (eg about neighbours gossiping, about partners having affairs, about being followed by MI5 and so on) and in the judgement of their plausibility is obscured.

5.5.4.3 Class and credibility

In the same way that the absent standard against which the supposedly paranoid subject is seen as a white (heterosexual) man so it is also classed. Spitzer's (1990) assumptions about how 'normal' beliefs are characterised by the possibility of intellectual debate and empirical investigation not only seem unlikely but also classed, representing an educational elite. We saw earlier how decisions about plausibility might be influenced by the diagnoser's assessment of the subject's previous employment, psychiatric history, 'social background', 'intelligence', 'education' and their having previously been a 'good member of society'. All of these too could be seen as linked to social status norms and, as a result, as classed. Thus the same belief could be seen as plausible for one person of a certain social status but as implausible for someone with a different social status. For example, sophisticated philosophical beliefs regarding lifestyle and diet might be accepted as plausible, if faintly eccentric, for a middle class intellectual but as a sign of pathology in a working class unemployed person with relatively little education.

Class can work in two contradictory ways in relation to paranoia. First, through a view of working class people being seen as particularly vulnerable to the development of psychiatric problems (Blackman, 1996) like schizophrenia and, perhaps, especially, paranoia. Thus it could be that beliefs might be seen not only as implausible but also as a sign of psychopathology in a working class as opposed to a middle class person. Second, by positioning people structurally in certain ways such that they actually are relatively powerless (see, for example, Mirowsky, 1985 and Mirowsky & Ross, 1983) and where the adoption of a 'paranoid' position, as we saw in chapter 3, becomes more understandable. Thus whilst beliefs of control and persecution by others might not be plausible for those with sufficient economic, social and psychological resources (ie middle class people) they might actually be more plausible (at least in a metaphorical sense) for those without such resources (ie working class people). However, because of the paradoxes of class it seems that those for whom such beliefs are more plausible are those most likely to be disbelieved because of their class position.

I noted earlier the notion that judgements of plausibility and rationality are moral ones (Ingleby, 1982) and depend on the inclination of the hearer and the distinction made by Forress Bennett (1997) between the plausibility of an account and the credibility of the account-giver. She noted how certain biographical aspects of the story-teller might affect their credibility and the perceived plausibility of the account. It is likely that class might work to undermine the credibility of user's views. The operation of class in this way can be seen in the following extracts.

Dave: Right. What do you think makes them think <pause> that things are, that some of your thoughts are paranoid? <Pause> How do they decide that, do you think?

Sharon: <Pause> Because a lot of the things, <pause> people have got their own lives and they wouldn't be so interested in me, they've got other things to be getting on with and why should anybody be saying it all the time, I suppose. <Pause> Erm like they've got their own lives to get on with and things. <Pause> Erm nobody, like, would be saying something like that every minute of the day <Dave: Uh-huh> <pause> even if they did, if they did want to upset me, <Dave: Uh-huh> er.

Sharon Harrison (Service-user)

Dr Lloyd: <Pause> Uh its inherently unbelievable <Dave: Right> the World Health Organization isnt interested in Alan Roberts, certainly wouldnt have been interested in him when he was five, promising him a load of money, certainly wouldnt have been sh-, I mean it just doesnt <Dave: Uh-huh> make <Dave: Uh-huh> any logical sense.

Dr Lloyd (Consultant Psychiatrist)

In both these extracts the speakers touch on the likelihood that someone would be interested in the service-user with the conclusion that no-one would be. Neither account gives reasons for why this should be the case. Rather there is an assertion that others would not be interested. What are the reasons, explicit and implied, for such lack of interest? In the first extract, Sharon's account draws on notions of motivation: others have 'got their own lives' (line 247). Of course, although people do have their own lives there is still plenty of interest in others since, to take two examples, most people gossip about others (Rosnow & Fine, 1976) and readership of tabloids and magazines exhibiting a prurient interest both in the rich and famous and ordinary people's extraordinary stories is high. In the second extract, there is an assertion that the WHO would not be interested in Alan. Such a belief is seen as not making any logical sense (line 147) although no evidence is presented against the idea other than the implication that it is implausible. But how does the implication of implausibility achieve its effect? There appear to be strong assumptions that, unless there are clear grounds why someone should be of interest to others, that their belief that others are interested in them is paranoid or grandiose. Of course, such an assumption might be even stronger if the person was working class. Indeed, their class position might even be seen as a functional reason for why someone should have such a belief. Dr Lloyd, at another point in the interview, notes that this belief has 'given meaning to a completely meaningless life' (line 175). The initial assumption that the user is not worthy of others' interest can also be seen in the extract quoted earlier in 5.5.2 from Dr Beardsley (from Harper, 1991). One can imagine that if Sharon and/or Alan were rich and famous then these beliefs might be seen as plausible and credible. Thus it seems that it is the diagnoser's perception of a disjunction between the subject's social status and their beliefs that signals a decision of delusion.

These two extracts contrast with other points in the interviews where diagnosers expressed the need for more contextualising information in order to judge the credibility of account-givers and the plausibility of their accounts. As Dr Chapman, recounted in the case of Mike Sullivan, it was difficult 'to tell whether it was paranoia or not' just on the basis of Mike's verbal account since it was 'reasonably near what could have been the truth' (lines 21-23). That is until he had information from Mike's wife. Other diagnosers pointed to other non-belief or non-rational criteria as I noted earlier. Biographical information was one such source of context and class formed an important part of this since education, employment and psychiatric histories were all seen as important in determining the veracity of a belief. In other words, being working class would not trigger off a search for other information prior to making a diagnosis. The use of biographical knowledge in making diagnostic decisions has been noted elsewhere (see, for example, Pfohl, 1978).

Of course, class not only affects how judgements about plausibility are made, it also intersects with the kind of interventions users receive since such decisions may depend on judgements of insight which is a classed notion (Smail, 1996b). We will discuss insight later in this chapter.

5.5.5 Rationality isn't the whole story

A fifth point at which the implicit rationalism of delusion diagnosis could be said to have unravelled was where aspects of a belief other than its veracity or na´ve rationality were highlighted. Thus, when delusions were seen as meaningful, or has having a grain of truth, or when the distress (or professional concern) caused by a belief was valorised in the interviews, considerations of rationality were not always seen as of most importance. The following three extracts illustrate these points. Coincidentally the best examples all come from the same interview although examples were to be found in other interviews.

5.5.5.1 Delusions as meaningful

One of the oppositions described in chapter 3 was that of form/content. I noted there how some have viewed delusions as 'empty speech acts' (Berrios, 1991). In contrast, cognitive-behavioural psychologists like Haddock & Slade (1996) have commented on the importance both of 'listening and attempting to make sense of the patient's symptoms and problems' and of 'acknowledging the meaning and role of the symptoms in the person's life' (p.xi). This continues a tradition of finding meaning in psychotic experience including anti-psychiatrists like Laing (1965), phenomenologists like Sass (1994) and critical professionals like Boyle (1997a). Such views were represented in the interviews and seemed to point to the inability of a solely rationalist and form-driven science to give an account of the cause and significance of delusions.

Julie: /They're trying to convey something, a sense of distress, of feeling persecuted but they're giving it a specific reference which may not itself be so, be true, in the sense of what is true that, be erm able to be proved, but yet the feeling, the experience that they're having is va-, is er real.

Julie Mason (CPN)

In this extract, delusions are seen in an almost metaphorical light. This is achieved here through the textual separation of the feeling of distress from an actual cause. Thus the 'sense of distress' (line 26) and the 'feeling' and 'experience' of persecution (lines 26-27 and 28-29 respectively) are seen as 'real' (line 29) whilst the 'specific reference' (line 27) -- ie the perceived cause -- may not be. Thus the term 'real' is used to refer not only to the veracity of a belief but also to the existence of a certain experience or feeling. Internal psychological mechanisms are implied here -- thus the service-user is seen as 'trying to convey something' (line 26) although whether this is seen as intentional or not is ambiguous. What is not said here that could have been? One alternative psychiatric view-point here might argue that, if there was no real cause for a belief then it was simply false and therefore meaningless. The move to separate meaning from the veracity of a belief is an important rhetorical move which again points to ambivalence in psychiatry's relationship with rationalism.

5.5.5.2 Distress and rationality

At other points in the interviews professional concern about users' distress was highlighted. Distress is at times noted to be a criterion for psychological intervention with delusions (see, for example, Chadwick, et al., 1996) in order to address the potential criticism of practising in a totalitarian manner. As we saw in chapter 4, distress was seen as an important issue by professionals and users (and sometimes was more important in triggering diagnosis than a belief per se) and was constructed in different ways in the interviews, for example as 'agitation'.

[Julie:] Erm so I would come to terms with it by saying "Well it's the degree of distress they had, it's causing that person". Presumably they've agreed, hopefully to some input from health professionals so they must have some level of feeling that it's distressing, is causing them a problem. Now that, I suppose it isn't always the reason why people come into the system. It may not be the level of distress, it may be the unusualness or the bizarreness or the <pause> the erm, erm unlikelihood of their paranoid beliefs being true, that other people have indicated the need to have, but I would hope I would personally try and focus on the distress.

Julie Mason (CPN)

Here, the speaker, notes how users may enter services because of the 'unusualness' of their beliefs (line 76) but that she prefers to focus on any consequent distress (line 78). Again, a purely rationalist and form-driven account is not given voice here -- for example, the formal diagnostic criteria are hardly mentioned apart from the bizarreness or unlikelihood of the belief (lines 75-76). Rather, ethical and humanistic discourses, for example the imperative to help others in distress, are drawn on. Another non-rational and, instead more political and ethical, reason for intervention was risk, as we saw in the previous chapter and this was used with similar rhetorical effect in the interviews.

5.5.5.3 The grain of truth in delusions

The previous two examples have pointed to a theme in the interviews that rationality was not the whole story and there was a need to draw on other accounts in dealing with delusions. However, there were points in the interviews where rationality turned in on itself -- occasions where supposedly deluded beliefs turned out to be at least partly 'true'. These are referred to in the literature as the 'grain' or 'kernel' of truth in delusions (eg Barrett, 1988). I have noted some of these 'truth games' earlier in this chapter and in chapter 3. To some extent these instances undermined the notion that delusions were always wholly irrational and false although, as I have noted elsewhere, the diagnostic discourse is flexible enough to warrant a diagnosis on the basis of other criteria (like the supposed illogicality of the belief or that the factual basis of the belief is actually a consequence of the belief -- see Harper, 1994b).

Julie: /I think there was a er a li-, there was some basis in reality quite clearly 'cause on more recent occasions when I was involved with, with him erm, you know I'd gone out to see him, that was when he'd driven the car towards the lads and his mum was there as well and she said "yes", she said had heard them <Dave: Uh-huh> you know, shouting abuse at him just totally unprovoked as they walked past. And, and within that area it seemed quite po-, common, you know, for people to pick on local <Dave: Uh-huh> people who they know, for whatever reason and shout names at them.

Julie Mason (CPN)

Category entitlement is employed in this extract as a way of providing third party evidence about the factual basis for Paul Dench's beliefs (indeed Dr Smith used this rhetorical strategy to claim that Paul's beliefs were false in the extract included in 5.5.4.1). Julie's response here implies a quantified view of reality in that Paul's beliefs are seen to have 'some basis in reality' (line 127, emphasis added). Thus the text works to avoid a dichotomous view of beliefs as either true or false. This, like the separation of feeling from causal events and the viewing of feelings as real works to undermine a purely rationalist view of delusions as 'false beliefs'. However, none of these extracts goes so far as to imply that delusions do not, as it were, exist. Rather, they could be seen as paradoxically enhancing the flexibility of psychiatric discourse through an ambivalent and ambiguous relationship with rationality.

5.6 JUDGEMENTS OF PLAUSIBILITY AND THE MANAGEMENT OF USERS' IDENTITIES

In the previous sections, I have attempted to provide a reading which exposes some of the contradictory assumptions of rationality manifested in decisions about the plausibility of beliefs. We have seen that not only are rationalist criteria applied inconsistently and that they do not work according to psychiatry's own canons of reliability and validity but also that non-rational criteria have a part to play in professionals' judgements of plausibility. Thus psychiatry is faced with a dilemma: it is charged with an imperative to mark out beliefs considered delusional as deviant but at the same time it proves so difficult to give valid reasons for such decisions according to its own canons (eg as rational, reliable and consistent etc). Whilst for traditional psychiatric and psychological researchers this might be seen as a problem to be resolved, here it will be seen as a topic for investigation. For example, this dilemma highlights that the notion of plausibility draws on rationality in an ambiguous and contradictory manner. This is not a new finding. Thus Ingleby (1982) notes the existence of sometimes subtle contradictions in the everyday use of psychiatric diagnosis. He goes on to comment that the 'systematic inconsistencies and injustices in the use of psychiatric concepts ... directly reflect political contradictions in the society in which they are deployed' (p.125, edited, emphasis in original). Contradictions cause problems for psychiatry yet, at the same time, they afford it flexibility in diagnostic decisions. Elsewhere, I have examined some of the dilemmas and traps such contradictions construct for professionals (Harper, 1991, 1994b). Here, however, I wish to focus on the implications such dilemmas pose for users of psychiatric services. For example, we saw in the previous chapter how Sharon was faced with competing imperatives to: warrant behaviour that others regarded as problematic through being seen as psychiatrically 'ill' and hence not willful; to be seen as a 'good' patient; and to present herself as an ordinary person who could be rational. In this section, I want to focus on two of the 'traps' in which users found themselves in trying to negotiate these competing imperatives against a background of discourses about plausibility and credibility. Finally, I will go on to discuss how assessments of plausibility are inextricably linked to judgements of oddness and bizarreness.

5.6.1 The rationality trap

Some of the accounts given by users could be seen as attempted solutions to certain dilemmas. One of the dilemmas they were faced with was that they were positioned as irrational because of their delusions. Thus one challenge for them was to prove that they were no longer irrational and were to be accorded the rights and respect due to ordinary members of society. However, responses to this posed other dilemmas. Firstly, the attempt to try to prove one's rationality risked them being further positioned as mad. Secondly, users may be expected to adopt a standard of rationality that most 'normal' people do not reach most of the time: not even mental health professionals always have rational beliefs backed up by evidence and we have discussed this reflexive problem earlier(11). Thirdly, rationality, as we have seen, is not necessarily the main factor in diagnosis since professionals draw on non-rational criteria. Indeed it is hard to think of purely rational criteria for judging plausibility -- surely such judgements would always incorporate some cultural assumptions? The notion of rationality itself, for example is one such cultural assumption as we noted in chapter 3(12).Thus users are positioned in a 'rationality game' where the aim is to be more rational than 'normal' people and professionals. In their attempts to make the implicit rules of this game explicit and be what we might term hyper-rational, they may be further marked out as different and as other.

Moreover, as Georgaca (1995) comments, the notion of rational reasoning presupposes not only assumptions about 'normal' people engaging in rational thought but also the existence of an 'objectively existing reality which is determinate, coherent and non-contradictory' (p.3), an assumption that has been challenged by social constructionist and critical realist workers. The question arises then about users being encouraged to adopt a view of the world which most people do not appear to use most of the time and which may not even be accurate.

An example may be useful to draw out some of these issues further. Section 5.5.2 included an extract from the interview with Dr Lloyd about Alan Roberts and two extracts from the interview with Alan. A further extract from the interview with Dr Lloyd can be found in 5.5.4.3. Dr Lloyd's position indicated that Alan was deluded and that even though there had only been minimal investigation he was sure a key character in Alan's story did not exist. Moreover he found it inherently unbelievable that the World Health Organization would be interested in Alan although again no reasoned argument or evidence was presented. In contrast, Alan alleged that doctors had made up their minds that he was deluded without adequate investigation.

What are some of the effects of these accounts? On the one hand, Alan created some space for resistance by claiming the moral high ground of rationality and empiricism. However, as we noted earlier, by this very action he then became marked out further since this rationality is heard differently because of the way he is positioned as patient in the psychiatric system. Thus Dr Lloyd would probably not see this rationality as a sign that Alan was getting better but, rather, as a sign that his delusion was held with firm 'unshakeable' conviction. Thus users are invited only in an ambivalent manner to be rational. Of course, power is a major consideration here and, as Heise (1988) has noted, in a struggle over views of reality those with greater social power will win. Thus through the use of category entitlements which carry greater force by virtue of his being placed in a position of greater social power, Dr Lloyd's account positions Alan as deluded. Moreover, Dr Lloyd's account is even able to include non-rational criteria. However, if Alan were to do the same this might well be considered as further evidence of his irrationality.

5.6.2 The insight trap

A variant to the rationality trap is one relating to 'insight'. Insight is a psychiatric concept referring to whether a patient is aware of:

the fact that she is ill and that the illness has affected her mind, and an awarenesss that certain experiences and thoughts are pathological.

Gillett (1995, p.227)

In this context it is slightly different from the way the term is used in psychoanalytic psychotherapy. However, it shares some similarity with this latter term in being open to criticism on the grounds that the resources (economic, emotional and so on) necessary for, and the language of, insight are classed (Smail, 1996b) in the same way as psychotherapy is (Pilgrim, 1997). Moreover, the whole notion of insight is flawed, Perkins & Repper (1996) argue, because it assumes that agreeing with one's doctor that one is mentally ill and agreeing to the remediation of and reconstruction of one's experience within the concepts of western psychiatry are desirable. Once again, then, insight is inseparable from considerations of power: professionals have the power to define what being 'well' means and if users disagree with this, or disagree that they are 'ill' then they are deemed to lack insight. This obviously runs the risk of seeing people with legitimately alternative views of their experience (eg those from ethnic and other minority groups) as lacking insight. If a person is deemed to lack insight then:

this gives the mental health worker a justification to disregard what they are saying (because they do not understand what is 'really' going on) and, if necessary, to treat them against their will.

Perkins & Repper (1996, p.167)

In contrast, Day & Bentall (1996) recognise that 'lack of insight' is better viewed as 'simply having a theory which is different to that of the relevant health professionals and at variance with the prevailing scientific paradigm of the psychiatric establishment' (p.251).

Although having been a little out of fashion in psychiatry with anti-psychotic medication (which required no insight in order to 'work') in the ascendant, insight is currently enjoying a renaissance with the development of psychological interventions for so-called drug-resistant psychotic symptoms. For example, Garety et al., (1997) reported that one of the best correlates of treatment 'outcome' for cognitive-behaviour therapy was a psychometric item relating to insight.

The dilemma for users is that in order to be considered 'well' and 'normal' they are required to demonstrate their rationality (which, as I noted above, marks them out as different for a start) and to acknowledge that they are ill. One might say that to be well requires acknowledgement of past illness but within psychiatric discourse the user is never considered fully cured. Rather, symptoms may be considered to be 'well-controlled' or 'maintained' if the user takes medication or 'in remission' if not -- a relapse is always expected. Thus to achieve a normal (ie well) status means, paradoxically, accepting a less than normal (ie ill) status. In an Orwellian twist, to be well is to accept that one is ill.

This trap touches more closely on the competing imperatives in which we noted Sharon was caught earlier. Users had to negotiate a delicate line between establishing that they were both 'well' and accounting for past 'illness'. In some ways this dilemma is similar to that in which people who have had paranormal experiences find themselves. Palmer (1997a) has noted some of these similarities, drawing on Wooffitt's work on accounts of paranormal experience (1991, 1992)(13). Potter (1996b) summarises Wooffitt's work on how people giving accounts of their paranormal experiences have two closely related tasks to attend to:

On the one hand, they have to demonstrate the factual nature of their paranormal experience. That is, they need to accomplish it as something out-there, as existing in the world rather than a mere product of fantasy or imagination. On the other hand, they have to show they are sane, rational, normal people. For when reporting experiences like this there is a danger of being written off as a crank or a mad person. This can be seen as a problem of managing the two available categories, normal and crank. The speaker must construct his or her account so it will be heard as coming from someone in the category normal and not the category crank.

Potter (1996b, p.140, emphasis in original)

Avery & Antaki (1997) note the use of 'normalizing' devices in reports of non-paranormal events where speakers made their stories play on appearance and reality. The need to demonstrate insight and normality and so using forms of normalizing rhetorical strategies required users to manage a delicate negotiation between these two categories as the following extract demonstrates.

Dave: Right. What do your family think about the kind of thoughts that you have, you know.

Sharon: They think I'm just being, they think I'm doing it for attention, I think because they don't think I'm mentally ill, like I've got a screw loose or anything like that, they just can't understand why I'm saying it 'cos I used to think they were playing records on the <pause> erm on the radio, things like that, a lot, just to get to me. <Pause> Erm <Dave: Who did you think was doing that?> Just some lads at work. <Pause> Er [sighs] it's hard to, it sounds really strange, like, saying it, but <pause> I did think it was true for a bit and I kept asking them who's, why're they doing it. <Dave: You kept asking your family or/> /Yeah, my family, my sisters, say mum and dad. <Pause> I know it's not true. I knew really, deep down, that there's no way anybody could have been doing that but I, in a way I wanted to believe it, I don't, I don't know why. <Dave: Uh-huh> <Pause> Maybe because I was lonely, I just wanted to feel like someone was saying, <pause> trying to help me out or something <Dave: Uh-huh>.

Dave: You know, when you were saying there some of the things that you've thought in the past, do you, are you, do you get embarrassed kind of saying those things/

Sharon: /I do telling you about the radio 'cos I feel like it makes me sound like some kind of nutter or something <Dave: Uh-huh> er <pause> and it, really I suppose, if, if I was a real, I wouldn't know <pause> know what was happening, I wouldn't be able to turn around and say 'well, you think I'm a nutter' so I can't be erm mentally, mentally ill or anything but it does sound strange to other people I think.

Sharon Harrison (Service-user)

At the start of this extract, Sharon's response suggests that she is, as Potter might say, attempting to manage the categories 'normal' and 'crank' or irrational Thus in her response to my question about 'thoughts' she contrasts 'doing it for attention' (line 361) which would imply normal willfulness with being 'mentally ill' (line 362) which would imply irrationality. Of course, as we noted in chapter 4, there are negative moral consequences of being seen as simply willfull as well and this might explain the variability in the text between the two categories.

Right at the start of her response Sharon begins to build a case that she is not mentally ill by suggesting that her family (who might be seen as third party witnesses) do not think she is (line 362). What alternative to a mental illness explanation is there? Sharon's response is that 'they just can't understand why I'm saying it' (line 363). It is unclear here what Sharon's own view is, although her account shows an awareness that some kind of explanation is required since her beliefs sound 'really strange, like, saying it, but' (lines 366-367). The 'but' here helps to provide some resolution between the fact that some of the things she used to think were considered strange and a view of herself as normal. This phrase, like those used by Wooffitt's participants, works to show that Sharon is aware of how extraordinary her beliefs might seem(14). She reinforces this later when she says 'it makes me sound like some kind of nutter or something' (lines 377-378).

Sharon's account could be seen as an attempted solution to the question of how she can explain having believed extraordinary things. In other words, how can Sharon demonstrate that she is now 'well' without having to concede that she was ever 'ill'. First she notes that she 'did think it was true for a bit' (line 367) but that now she knows it is not true (line 369). Then she goes on to say that she 'knew really, deep down' (lines 369-370) that it was untrue. The use of a depth metaphor here accounts for why Sharon might have appeared to believe these thoughts but that really she was rational and that the beliefs were a temporary and superficial aberration.

Second, Sharon needs to account for why the aberration occured. She becomes more speculative here, offering both an agnostic account ('I don't know why' [line 371]); and a psychological one ('in a way, I wanted to believe it' [lines 370-371] perhaps because she was 'lonely' -- line 372). Finally, she provides further evidence against the 'nutter' interpretation of her behaviour. She argues that if she was a real 'nutter' she would not have had any awareness that what she was saying was strange. Here she uses an extreme case formulation, drawing on popular psychiatric representations of psychotic people as people with no insight and who are thus not aware of the strangeness of their behaviour and are not amenable to rational thought.

Palmer's (1997a) work suggested that those diagnosed with paranormal delusions in his study did not manage this dilemma well since they did not appear to take into account the fact that hearers would find what they said as odd and thus events were:

not reported so as to display that the teller found its paranormal aspects extraordinary. More concretely, delusional accounts do not include any account of the initial reaction to the paranormal events which embodies an ordinary thought. From this, and the ordinary intonation with which paranormal events are recounted, it appears that the teller finds nothing remarkable about meeting Thor or being pursued by smaller devils.

Palmer (1997a, p.134)

The ability to take account of the hearer's perspective might be seen as a criterion for normality, or at least insight. The extract from the interview with Sharon suggests that this may be an overgeneralisation and may lead to the unnecessary essentialisation and homogenisation of the categories 'deluded' and 'normal'(15). But what if there were differences between the way 'deluded' and 'normal' people accounted for their experiences? In the interviews I conducted, most interviewees who had been users of psychiatric services appeared to demonstrate an awareness that some of what they currently, or had in the past, believed would seem strange to others. However, there were a few rare points at which there was a breakdown of understanding between me and the interviewee, where plausibility and understandability were stretched to breaking point. In the next, and final, section, I will focus on how such breakdowns might be seen as revealing the influence of the speaker's and hearer's assumptions rather than the extent of the speaker's psychopathology. I will then go on to discuss how the user's awareness of the possibility of such breakdowns was an important influence in how they negotiated their accounts.

5.6.3 Plausibility and the accomplishment of oddness, bizarreness and implausibility

We saw in chapter 2 how individuals and groups may be 'cut out' and positioned as paranoid in popular culture when their views seem strange. Occasions of breakdown in plausibility could be seen as opportunities for such cutting out. In this section I will focus on questions like 'how did such breakdowns occur in the context of these interviews?', 'how was oddness accomplished?' and 'what cultural assumptions are drawn on in positioning the other as odd?'.

Palmer's (1997a) research suggests that what marks out the deluded person is not only the absence of particular linguistic practices but of orientations which would indicate an acknowledgement of the hearer's perspective(16). In contrast, Georgaca (1995) has focused on the interaction between speakers and hearers:

In the process of constructing and negotiating reality participants are also constructed as mundane reasoners. They position themselves as individuals who share, and can make use of, the mundane assumptions about the world and the processes through which knowledge of the world is acquired, presented and accounted for. Moreover, they position their co-participants as individuals who are able, and are expected, to behave in the same way.

Georgaca (1995, p.5)

Georgaca argues that supposedly deluded interviewees share commonsense assumptions about how claims are made and negotiated and are willing to account for their statements (eg through providing evidence and answering challenges). Moreover, she asserts that delusions are meaningful because they 'employ culturally available discourses and discursively adequate strategies for their construction' (p.7). Thus instead of lacking linguistically demonstrable skills of rational thought (as Spitzer, 1990, might suggest) she comments that:

disputes over claims, even when the claims are about what appears to be external reality, take the form of disputes over culturally available interpretative frameworks. The issue of which one is right over the other can only be resolved if one interpretative framework is a priori considered to be the one that accurately describes reality.

Georgaca (1995, p.7)

Georgaca, therefore, highlights the importance of 'interpretative frameworks' which could be seen as cultural assumptions. In common with her, I will argue that the breakdown of plausibility and understanding does not lie 'in' the supposedly deluded person's talk but, rather, between the speaker and hearer since the speaker fails to provide what the hearer expects -- ie there is a breach in expectations and assumptions between speaker and hearer. My argument is not that many people (including myself) would not find some views odd but, rather, that they are not necessarily odd in and of themselves because of the structure of talk. Instead it is the talk's failure to conform to hearers' expectations that renders it odd. And the hearer's expectations are culturally bound. As a result, then, if there is a claim made that a person is deluded, a counter-claim that the hearer is closed-minded would be equally-well founded and, indeed, this is the source of much humour in the psychiatric system survivor movement -- cf Lowson's (1994) concept of Professional Thought Disorder.

In the context of discussing reflexivity in DA, Potter (1988) has argued that it is a reflexive practice, a debate with our own taken-for-granted reading practices and notes that:

part of the process of analysis inevitably involves a critical interrogation of our own presuppositions and unexamined techniques for sense-making. The analyst constantly has to ask: why am I reading this passage in this way?

Potter (1988, p.48)

In this section I wish to focus on these taken-for-granted hearing and sense-making practices, adopting a more reflexively-aware approach to DA.

5.6.3.1 Plausibility breakdowns and the breaching of cultural assumptions

In the following extract, we will see how such breaches in assumptions occur. I have been talking to Alan about the robbery which resulted in a violent assault which led to his confinement. I am asking him if he feels the World Health Organisation (WHO) were involved in the incident.

Dave: Right. But you don't think they caused you to murder this chap?

Alan: Well people <pause> there were those two prison officers caused it. <Pause> <Dave: What, by saying you'd be in prison soon?> No. <Coughs> They, <coughs> these two prison officers, <pause> they used what they call a golden gun <pause> to, to pull this into the future to make it happen. <Pause> It's a sexual thing where they save up their sexual stuff. <Pause> And <pause> they made it happen.

Dave: Tell me a bit about that. I'm not sure I follow that [inaudible] a bit of an explanation.

Alan: <Pause> [Sighs] It's difficult to explain it. <Dave: Uh-huh. What, what's the golden gun?> It's when they save up their sexual stuff, when they don't come for ages <Dave: They save up their semen?> Yeah. <Dave: Yeah> And then they can project <pause> what they want to happen in the future <Dave: Uh-huh> when you come <Dave: Uh-huh> and that pulls it into being, pulls it into happening.

Dave: <Pause> And they were, er, were they linked to the World Health Organisation then?

Alan: Well they knew about it, they knew about the twenty five years <Dave: Right> and they asked me if I wanted to come into prison a number of times or all in one go. <Dave: Uh-huh> I didn't think anything of it, I didn't think they could do anything like that so I said 'Yeah, all in one go'll do' <laughs>.

Dave: And when you, I mean have you told many people about these er these thoughts that you have, these ideas?

Alan: Yeah, there's nothing wrong with me. <Dave: Uh-huh> It's because it's a lot of money er and it sounds weird.

Alan Roberts (Service-user)

Up until this point in the interview I have been able to interpret Alan's views that he has been in prison because of a conspiracy by the WHO as plausible and this is evidenced by my ability to continue conversing with him. However, when, at line 89, he talks of a 'golden gun' which appears to make time travel possible (lines 89 and 97-99) and which appears to use semen (lines 90 and 95-96) this assumption of plausibility is breached. Although I find it infinitessimally unlikely that the WHO would embark on such a project I find it plausible (ie at least possible and coherent) within my assumptions about the world. However, discussion of time travel, especially when it seems to involve means (ie semen) which appear to me as bizarre, is beyond what I can count as plausible although it makes sense grammatically(17).

It is possible to track my response to this in the extract. Initially, at line 92 I make a neutral response asking for further clarification. The phrase 'tell me about that' which I use at this point is almost a counselling clichÚ and its effect is to invite the speaker to continue whilst the hearer's view remains ambiguous. I then ask specifically about the golden gun (lines 94-95). Alan again explains that this involves 'sexual stuff' (line 95). I then ask specifically about this 'they save up their semen?' (line 96). Although the transcript is not detailed enough to support a more finely detailed analysis and there is not space to present a longer portion for comparison, it appears that I begin to ask fewer and fewer specific questions. It is almost as if I have decided that I will not be able to render Alan's views as plausible and therefore I remain non-commital. Rather, after a pause, I change tack and ask about the WHO again (line 100-101). Later, I ask Alan whether he has told 'many people about these er these thoughts that you have, these ideas?' (lines 106-107). By rendering Alan's statements in the realm of thoughts and ideas rather than the world of facts and reality I appear to be doing some work to render Alan's account plausible by describing them as thoughts rather than a view of the facts. Alan appears to respond to this by mounting a defence against my implied challenge when he says 'there's nothing wrong with me' (line 108) whilst acknowledging his position 'sounds weird' (line 109).

This extract is interesting because up until this point we have been able to maintain some understanding because of the following assumptions, some of which are evidenced in the extracts: that though Alan's views are unlikely they are plausible (ie possible); that I feel there is meaning in such views; and that professionals can all too lightly dismiss views as delusional because, at first sight they seem a little strange. However, at this point, Alan breaches even my fairly liberal assumptions and so becomes marked out and cut out as delusional by me.

It is interesting that, despite this breach, Alan continues to show an awareness of the hearer's perspective in lines 108-109. As in the extract from Sharon's interview, discussed above, Alan manages the categories of normal and irrational. First he says 'there's nothing wrong with me' (line 108) demonstrating his awareness of a possible challenge. Second he notes that his account 'sounds weird' (line 109). Finally, he provides an explanation for why others might not believe his version of the facts. This is necessary to defend against the challenge that others do not believe him because he is irrational. The reason for disbelief is, he claims, because of the involvement of a 'lot of money' (line 109).

This latter point is important since, although such breaches did occur, they were a fairly rare occurrence, perhaps because of my liberal assumptions (although I would not wish to claim that I would necessarily have agreed with what my interviewees told me, merely that what they said merited further investigation). A more common occurrence was for service-user interviewees to demonstrate their awareness of the possibility of a breakdown of assumptions and plausibility. Such awareness was rhetorically accomplished in much the same way as 'insight' which we examined in 5.6.2.

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

Dave: Were you easily upset at that time?

Mike: I wasn't no, I was just, I was like a zombie, there were that much drugs, that many drugs inside me. Four hundred milligrams of Chlorpromazine is a very high dose, I mean usually they go up to 200 mg. <Pause> I suppose he thought it was because of my size. <Pause> <Dave: Uh-huh> Er so I came out of the, I came out of the delusion very quickly, over a day or two <Dave: Right> but then as I think I mentioned in the er, the article that I wrote <Dave: Uh-huh> I didn't mention it because, you know, of this business of family background whereas my wife's uncle and you could, you could, if you like check this with my wife 'cos obviously <Dave: Right> you're not going to think "I can't [laughs], you know I can't accept necessarily everything that somebody who's, who's diagnosed as paranoid is going to say" so you might think, if you want to, feel free to ask my wife/

Dave: /Well I kind of feel agnostic on these things. I mean I don't <Mike: Yeah> believe or disbelieve people I'm just curious/

Mike: /Well you can do, yeah. I mean, what I'm saying is my wife will confirm this <Dave: Right> and in fact she sent a letter to Dr Smith and if you want to see that letter <Dave: Right> feel free to <Dave: Right> which confirmed that her uncle served with British Intelligence.

Mike Sullivan (Service-user)

As with the extracts from the interviews with Sharon and Alan, Mike is clearly negotiating between the categories 'normal' and irrational. Thus he expects that I may disbelieve him and assumes that I will not be able to 'accept everything that somebody who's ... diagnosed as paranoid is going to say' (lines 91-92). He implies that to accept everything that such a person would say would be unwise and this view is strengthened by the use of the word 'obviously' (line 90), his laughter (line 90) -- which, literally, appears to imply that such an approach would be laughable -- and his offer of my checking the facts with his wife which is stated twice (lines 89-90 and 96).

Elsewhere in his interview Mike appeared to demonstrate that he was 'well' by distancing himself from his previous beliefs. Thus, after discussing some of his views he noted 'you can see how the sort of crazy reasoning went' (lines 117-118). At other points, he demonstrated a high degree of psychiatric knowledge as a result of reading psychiatric texts and writing notes about his experiences. Moreover, he also demonstrated an awareness that others might find his views strange. Thus he noted that 'if you go in there and you say to people that your grandfather was a member of the IRA ... and that your wife's uncle served in British intelligence ... well, you know it's such a dodgy business. It's the sort of thing that mental patients are gonna when they go into hospital ... if I say that and I'm disbelieved, I could be in here for a hell of a lot longer' (lines 283-294, edited).

5.7 DISCUSSION

In this chapter, I have examined the notion of plausibility and described some of the rhetorical strategies involved in constructing im/plausibility and rationality. I have presented a reading which highlights the importance of assumptions of the unitary rational (gendered, raced and classed) subject in making judgements of plausibility. I have argued that the concept unravels and that the very ambivalence of the psy complex's relationship with rationality provides a flexibility in diagnostic decision-making. I have gone on to examine some of the traps and dilemmas psychiatric service-users have to negotiate as a result.

So far in this analytic section we have examined the cluster of emotions, beliefs and actions associated with paranoia which might work to position a person in front of a GP or psychiatrist. In this chapter we have discussed some of the influences on those professionals' judgements of plausibility which would determine whether the person developed a psychiatric career. The following chapter concerns the next step that would occur in such a career: professional intervention. Given that the dominant form of intervention for this group of users is medication (Rogers et al., 1993) this will be the major focus of chapter 6.


1. Palmer (1997b) notes that data generated from these interviews pertains to what people say they base decisions on rather than on what they actually base their decisions on in practice and, in fact, in my introduction to Part II I noted this had been an original aim foiled by practical difficulties. However, I use my interviews with service-users to touch on this issue. Moreover, I am not simply examining the reasons professionals give for decisions but also looking at how culturally available strategies and discourses are taken up in interviews and there is no evidence that similar strategies would not be culturally available in diagnostic interviews too.

2. DSM-IIIR gave a greater weight in the diagnosis of schizophrenia to the judgement about whether a delusion was bizarre or not (Flaum et al, 1991). Whilst 'bizarre delusions' are seen as a certain category of content (eg like grandiose) and so would be seen as separate from paranoid or persecutory delusions many definitions of bizarreness are based on a judgement of plausibility -- DSM-IV defines a bizarre delusion as one that 'involves a phenomenon that the person's culture would regard as totally implausible' (APA, 1994, p.765) and such a judgement seems the central judgement in deciding whether a belief is delusional at all (Maher, 1992). Thus the literature on bizarre delusions is worthy of note here.

3. In this and the other studies on reliability discussed here, samples of delusions were given in clinical case vignettes. Of course, these vignettes are discursively organised to serve a particular purpose and are stripped of a good deal of the interactional and other context in which a 'delusion' would be performed.

4. Of course, a criticism of this argument is that terms like bizarre, delusion, implausibility, paranoia and so on are not being used precisely. Yet, this would be a discursive move to limit consideration despite the apparent evidence that the literature contains wide variation on what the 'proper' meaning and use of certain terms is.

5. Such an approach fails to recognise the multiple functions that talking about beliefs might serve (Harper, 1992). It is possible to critique such views as importing a rationalist and mechanistic view of belief which appears to lack any insight that might be gained from the study of how people with strong beliefs talk (Billig, 1991a, 1991b). Indeed there is a potentially fruitful area of research which looks at 'delusions' and other accounts of 'normal' beliefs from a rhetorical point of view. Georgaca (1995) for example, notes how conviction 'is not an internal state of certainty concerning the truth of a statement. Conviction is a rhetorical effect of the strength with which statements are defended and negotiated' (pp.7-8).

6. O'Connell & Whelan (1996) have noted how public estimates of crime in Ireland do not reflect official figures. The highest estimates of increase in crime prevalence were made by women, older people and readers of tabloids and Independent Group newspapers and this was not explained by the likelihood that they had been a victim.

7. There are dangers in seeing these categories in isolation. Frable (1997) notes how much research focuses on social categories one at a time and comments that this 'fragments the literature and systematically excludes particular populations' (p.155). She argues instead for the need to see identity as a 'continuously re-created, personalized social construction that includes multiple social categories and that functions to keep people whole' (p.155). Parker et al (1995) note how each of us is 'multiply positioned in terms of these different characteristics and thus our experiences are sometimes similar, sometimes different but always contradictory' (p.47). Moreover, Wong (1994) points out that 'different multiple positions may privilege, subjugate and (dis)empower all at the same time' (p.135). She goes on to argue that 'any dialogues that attempt to problematise issues of privilege and normality have to take into consideration the intricate webs of privilege, 'whiteness', heterosexuality, able-bodied, middle class and youth' (p.138). Thus, for example, in considering the extract in which I focus on gender we must keep in mind that Paul is white and working class as well as a man. Although it can be tactically helpful in analyses to focus on particular aspects there is a need to theorise subjectivity as consituted by a diverse cluster of social categories.

8. The 1995 official English and Welsh statistics on crime show 474 males were victims of homicide compared to 225 females (HMSO, 1996). Males under the age of 1 and aged between 16-50 were most at risk. It is accepted that official figures of reported crime underestimate the number of actual incidents, especially those where there is more stigma attached (as in the case of domestic violence). The British Crime Survey tries to get around this problem by surveying people and asking of their experience of crime. The 1992 British Crime Survey (HMSO, 1993) notes that more males than females were victims of violence occuring on the street, in and around pubs and clubs, at work and at home. For mugging figures were similar. For domestic violence alone, female victims outnumbered male victims. The elderly were rarely victims. No figures comparing the relative risk of sexual offences by age or gender were recorded although in 1995 there were 30,300 sexual offences recorded and it is likely that there are more female than male victims. Ferraro (1996) reported that women were more afraid than men of victimization, especially of sexual assault. It is likely that in terms of sexual and domestic assault women are more at risk and this may account for the greater perception of risk generally (Hollway & Jefferson, 1997).

9. Increasingly discursive commentators have begun to theorize absence and silence (Mandy Morgan, 1998; Wetherell & Potter, 1998). Thus Parker (1992), as we have noted, notes the importance of what is not said in texts. Stowell-Smith (1996) has explored why there are fewer black people diagnosed as psychopaths than one might expect given a general over-representation in mental health statistics. Ullah (1996) has examined the relative absence of black parent governors on governing boards and in her own research as well as a lack of information. Aitken (1996), writing about black women in mental health services has talked of an opposition between a present absence and a pathologized presence. Of course these concerns are likely to be even more absenced with a white, male professional as interviewer as in this study.

10. The 1992 British Crime Survey indicates that Afro-Caribbeans are more at risk than whites of muggings, domestic violence, violence near the home and on the street. Asians are more at risk than whites of muggings and violence near the home. Asian victims said, on average, that 37% of all violent incidents were racially motivated. For Afro-Caribbeans the average was 27%.

11. Indeed, Taylor (1991) has argued that some degree of positive illusions about reality are functional for mental health.

12. Palmer (1997b) makes the interesting point that in Wittgensteinian terms we might talk of delusions as moving beyond the assumptions of a form of life. He notes that this position is similar to that adopted by Coulter (1973) and Sass (1994). Like Ingleby (1982) I would acknowledge this but note that I would not necessarily agree that the assumption of 'common-sense' understanding in ethnomethodology (upon which such a position rests) is not free of contradictions or the effects of power. Rationality is only one form of life and it would not be appropriate to assume it is universal -- I would be concerned to point out the legitimacy of a diverse range of forms of life. Moreover it would not be appropriate to use the terms of this form of life to judge other forms of life.

13. Palmer attempts to 'recover some of the grounds on which delusions with a paranormal content differ from their non-pathological counterparts. That is, I have attempted to recover some of the ways in which a hearer may go about locating a particular form of psychotic symptom merely by examining how a paranormal story is told' (1997a, p.134). This might be seen as uncovering the real basis of psychiatric decisions, rather than the highly formalised versions found in DSM-IV.

14.Palmer (1997b, 1998) notes that Wooffitt's devices are quite specific (ie 'I was just doing X, when Y' and 'At first I thought...') and are not present here. I do not mean to claim this, however, rather I am noting the presence of the speaker's general orientation to the likely interpretations of the hearer (ie that what Sharon is saying makes her sound 'like a nutter'). Palmer notes that this is in response to my question and is not part of Sharon's initial account. My view would be that this privileges sequentiality and I would take a more interactive and dialectical view: is there evidence that the speaker can evidence awareness of the hearer's point of view? A further challenge is that this awareness may indicate Sharon's 'recovery' but I think this is too simplistic since some users seemed relatively committed whilst others seemed more ambivalent and she could still be diagnosed as delusional but in remission.

15.Palmer (1997b, 1998) notes that he does not seek to generalise either beyond paranormal delusions in general or beyond the cases he investigated. He comments, however, that the lack of reporting of 'ordinary' first thoughts in building an initial version of events and the lack of surprise evidenced in the extracts reported here is consistent with his account of delusions.

16.Palmer's work appears to presuppose a difference between these two groups, implying that such delusions are obviously recognisable, drawing on commonsense understandings. Of course, this assumes that psychiatrists would differentiate between the 'normal' paranormal experiencer and the supposedly deluded person. However, there is a possibility that they may not (at least not with a high predictability and reliability) -- it may just be that the latter group happen to end up in front of a psychiatrist because of other factors. Palmer (1998) acknowledges that his materials represent an impoverished situation but he contends that the talk of his participants would be readily identifiable by others as delusional although he gives no empirical evidence for such a claim. It is not necessary for the purposes of my argument to agree with this, that is, to assume that a hearer's perception of a speaker's oddness would command universal agreement, merely that there is the possibility of a breakdown in the assumption of plausibility between speaker and hearer.

17. In this sense it would count as a belief which is unfalsifiable because it does not follow assumptions like the continuity of time (Walkup, 1990). Of course this is compounded by the fact that Alan gives few details of how the time travel might be possible and I ask few questions about it.

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