Identifying delusional discourse: issues of rationality, reality and power

This paper addresses a foundational issue at the interface of psychiatry and medical sociology; namely, how the judgement of pathology is made. In particular, it examines a debate over how the symptom of delusion is identified. The psychiatric approach is realist in orientation with delusions being commonly defined in the American Psychiatric Association’s Diagnostic and Statistical Manual as ‘incorrect inferences about external reality’. However, from a social constructionist perspective, delusions are reconceptualised as the product of a power relationship in which the views of a less powerful patient are pathologised. Reviewing this argument reveals a number of ways in which constructionist sociology is critical of the psychiatric approach. However, the ‘debate’ has a paradoxical quality in that, although the constructionist critique addresses psychiatry’s foundations, it has been largely ignored. An ethnomethodological analysis of delusion is offered which attempts to account for, and move beyond, this paradox. This involves developing criticisms which are responsive to the sorts of phenomena that clinicians deal with. In other words, the argument points towards the development of a sub‐discipline that deals with clinical phenomena and hence might be called ‘clinical sociology’.