The Role of Psychological Harm in Delusions: a reply to Graham

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Trinkle, Dennis
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conference paper description
In recent work George Graham (2010) develops and defends a realist account of mental disorders, along the way offering a challenge to the "standard view" of delusions. He begins with a symptom-focused challenge to categorical discussions of disorder, introduces a novel way to consider the nature of delusions, and proposes a significant revision to the dominant paradigm for delusions. Judgments about delusions should be based on its "downstream" effects on a person's life rather than solely the "upstream" causes of the state. This account is worth considering for its own merits but also serves as an illustration of how judgments about disorders are tied to normative judgments, a state that has provoked much skepticism. However, my objections to Graham's account also illustrate how we can improve the normative judgments that disorders judgments rely on so that their contested nature need not substantiate the objection to disorder judgments that they are too contested to be objective. In particular, I argue that Graham gives insufficient attention to the context of evaluation, confuses two kinds of understanding delusions, and fails to take seriously the basic harm of delusion. First, attending to the context of a person's life and how certain events, like delusional experiences, shape it requires that we balance concerns about prima facie harms with the all things considered value of such events in a person's life. Second, the study of delusions requires a certain kind of reflective understanding that Graham successfully exploits to argue for the significance of downstream effects in determining when a person suffers from a delusion. However, this kind of understanding is unconstrained by the pressing needs of the individuals who come into the care of mental health professionals. In such cases, it seems the imperative to help may give pragmatic reasons to favor understanding delusions in terms of their upstream causes, contra Graham. Finally, Graham tacitly accepts the idea that disruptions of reliable contact with the world need not be serious harms. This is a substantive normative claim and needs to be defended. In each objection, then, we can see how the larger issue of understanding mental disorders is inextricable from questions of good lives, the responsibilities of medical personnel, and the significance of intact psychological processes for a good life and thus what counts as a harm. One of the significant challenges to understanding mental disorders is how to understand the role of values in understanding and treating disorders, and looking at a novel account of delusions illustrates how implausible it is to imagine we can avoid normative judgments when defining or diagnosing mental disorders.