In Defence of Madness: The Problem of Disability

My essay, about to be published in the Journal of Medicine & Philosophy.

I write defending mad positive approaches against the tendency to adopt a medical view of the limitations associated with madness. Unlike most debates that deal with similar issues – for example the debate between critical psychiatrists and biological psychiatrists, or between proponents of the social model of disability versus those who endorse the medical model of disability – my essay is not a polemical adoption of one or other side, but a philosophical examination of how we can talk about disability in general, and madness in particular.

You can read the essay here: IN DEFENCE OF MADNESS

And here is the abstract: At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgements, and the second from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism; the applicability of the social model to madness; and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter

Beyond Dysfunction: Distress & the Distinction Between Social Deviance & Mental Disorder

Over the course of last year I have been working on a small project with Rachel Bingham examining the possibility of distinguishing ‘social deviance’ from ‘mental disorder’ in light of recent work on concepts of health. The result was an essay published recently in the journal Philosophy, Psychiatry & Psychology (21:3-September 2014).

Johanna Moncrieff and Dan Stein wrote commentaries on our essay to which we responded in a short piece published in the same issue with the original essay.

In our response to Moncrieff and Stein we found it necessary to point out that in the writings of some critical psychiatrists and psychologists there is a problematic conflation of empirical with conceptual issues in relation to ‘mental disorder’. That section is reproduced below. Note that Criterion E is the final clause in the DSM definition of mental disorder. It states that a mental disorder must not solely be a result of social deviance or conflicts with society.

Mental Disorder: Separating Empirical From Conceptual Considerations

Let us begin by revisiting the conceptual basis of attributions of mental disorder. Criterion E is not, as we argued with Stein et al. (2010, 1765), conceptually necessary, but is of ethical and political importance given the historical context. Thus, notwithstanding the other criteria, a condition can only be considered for candidacy for mental disorder if “dysfunction” is present. What is a dysfunction? As Moncrieff puts it, there is a tautology in the definition of mental disorder where it is stated that a mental disorder reflects an “underlying psychobiological dysfunction” (Moncreiff 2014). Moncrieff argues that this is flawed because underlying processes have not been established, which renders the definition tantamount to saying that a dysfunction is a reflection of a dysfunction: a definition that adds nothing to our knowledge.

Here Moncrieff follows Thomas Szasz in finding a lack of resemblance to physical disorder to be the primary problem with the concept of mental disorder (see Fulford et al. 2013).1 In pursuing this, the critical psychiatrist not only fails to see the complexity of the concept of physical disorder, but also commits the same error as the biological psychiatrist. The latter implies that an ever longer awaited complete neurochemistry of mental health conditions would solve the conceptual problems. The former—the critical psychiatrist—implies the converse; that the absence of proof for the “existence of separate and distinct foundational processes,” as Moncrieff (2014) puts it, proves that mental health conditions are not disorders. As we have argued elsewhere, identifying the biological basis for a set of behaviors or symptoms does not in itself pick out what is pathological or disordered: for example, a complete description of the neurochemical states governing sexuality would not permit the inference that homosexuality is a disorder, any more than discovery of the neural correlates of falling in love or criminality would make these mental illnesses (Bingham and Banner 2012). Neurobiological changes—their presence or their absence—tells us about conditions when we find them by other means, but it does not tell us what is or is not a disorder. The same arguments could be run for underlying psychological processes. Consequently, emphasis on scientific progress or failure to progress in understanding the neurobiological correlates of mental health conditions does little to advance the conceptual debates, a point that may help to explain the impasse in the ongoing exchange between critical and biological psychiatrists.

Thus, although Moncrieff is right in pointing out that the term ‘dysfunction’ is redundant in the definition of mental disorder, she is wrong about the reason why this is so. It is not, as she claims, due to the point that no “separate and distinct foundational processes” (2014) that can ground dysfunction have been discovered empirically. After all, this leaves her open to the simple response that they actually have been, a response many biological psychiatrists do offer. The redundancy of the term ‘dysfunction’ in the definition of mental disorder is a result of conceptual analysis (and not empirical evidence), whereby it has not proven possible to define dysfunction in a way that excludes values. Here, we follow Derek Bolton in the view that once we “give up trying to conceptually locate a natural fact of the matter [dysfunction] that underlies illness attribution… then we are left trying to make the whole story run on the basis of something like ‘distress and impairment of functioning’” (2010, 332). We are left then with those things that matter in real life, the reasons that lead to healthcare being sought: usually the presence of significant distress and disability.

This is what the terms ‘dysfunction’ and ‘mental disorder’ pick out once we achieve some clarity on their referents. Stein is clearly aware of the problems inherent in defining dysfunction. However, somewhat surprisingly, the assumption that we can talk of ‘dysfunction’ over and above experienced factors (distress and disability in particular) arises through Stein’s commentary. In other words, although Stein has acknowledged the conceptual problem, in places he still writes as if there were a clear definition of dysfunction, without telling us what this would be. For example, he describes “situations when there is evidence of dysfunction, but an absence of distress and/or impairment” and gives the example of tic disorders which have no “clinical criterion (emphasizing distress and/or impairment)” (Stein 2014). We would argue that, despite the lack of explicit acknowledgement in DSM, tic disorders enter the manual because of their association with clinically significant distress and disability. It is important to avoid confusing the empirical questions (e.g., Why do people have tics? Can people have tics and not be distressed?) with the conceptual questions (e.g., When is a tic a disorder? Can tics be disorders if they do not cause distress or impairment?).

A further potential pitfall is to conflate the technical use of ‘dysfunction’ with the ordinary use of that term. This might occur where, on the one hand, we perceive a ‘dysfunction’ but on the other hand we are unable to say what the dysfunction consists of. When Moncrieff writes that dysfunction and distress are not co-extant, because, “people may neglect themselves and act in other ways that compromise their safety and survival without necessarily being distressed,” she is offering a description of behavior many would consider ‘dysfunctional’ in the lay sense (2014). Considered as a basis for conceptual analysis, however, this does not illuminate any “underlying psychobiological dysfunction”, which previous definitions aspired to do. Indeed, it is somewhat surprising that Moncrieff provides this counterexample rather than sticking to her argument that dysfunction in fact does not exist. In citing safety and survival, Moncrieff’s phrase does resemble the evolutionary theoretic approach (notably described in Wakefield’s Harmful Dysfunction Analysis), which as has been discussed widely elsewhere and noted in our paper, has fallen out of favor owing to problems with evolutionary theory specifically and naturalistic definitions in general. What of importance is left in Moncrieff’s putative definition if not underlying psychobiological and evolutionary dysfunction? We would argue: only the harm or threat of harm experienced by the individual, whether that harm is cashed out as distress and disability or as some other similar negatively evaluated experienced factor.

Response to the commentary on ‘A Critical Perspective on Second-order Empathy’: Phenomenological psychopathology must come to terms with the nature of its enterprise as a formalisation of folk-psychology (and the permeation of this enterprise with ethics)

[A response to the commentary by Jann Schlimme, Osborne Wiggins, and Michael Schwartz on my essay published in Theoretical Medicine Bioethics, April 2015 (36/2).]

In a recent polemic against certain increasingly dominant strands of phenomenological psychopathology, I launched a critique of the concept of ‘second-order’ empathy. This concept has been proposed by prominent psychopathologists and philosophers of psychiatry, including Giovanni Stanghellini, Mathew Ratcliffe, Louis Sass and others, as a sophisticated advancement over ‘ordinary’ or ‘first-order’ empathy. The authors argue that this concept allows us to refute Jaspers’ claim that certain psychopathological phenomena are un-understandable, by demonstrating that theoretical sophistication allows a ‘take’ on the these phenomena that reveals them as meaningful in the context of the person’s ‘life-world’. In my essay I argued that, given its philosophical commitments, the second-order empathic stance is incoherent, and given the constraints it places on the possibility of recognitive justice, it is unethical. The commentators take issue with both these points, to which I now respond.

First critique: ‘Psychopathology is not first philosophy’

In a succinct yet accurate summary of the first part of my argument the commentators write:

Rashed first addresses the issue of the feasibility of psychopathologists engaging in second-order empathy with persons with psychotic experiences/schizophrenia … [He] marshals textual evidence that psychopathologists can only make their case for second-order empathy by showing that it requires the performance of the Husserlian ‘phenomenological [transcendental] reduction’. Then, by citing phenomenologists such as Merleau-Ponty, as well as developing his own arguments, Rashed maintains that phenomenologists themselves do not agree that the phenomenological reduction is even possible. Assuming now that this conflicting reasoning demonstrates the impossibility of performing Husserl’s reduction, Rashed concludes that second-order empathy is impossible (because such empathy presupposes the successful performance of an impossible reduction).

Now their critique: the commentators begin by pointing out that the “‘transcendental reduction’ is designed to reach the level of a ‘transcendental consciousness’, which is the subject matter for a ‘first philosophy’ (namely, transcendental phenomenology) [that] can supply the foundation for all of knowledge”, a characterisation with which I am in agreement. I would go further and state that I consider, together with a long line of modern philosophers from Hegel to Wittgenstein, that such a project cannot work: we cannot get behind knowledge in order to establish the grounds for certainty of knowledge. As Hegel put it in his Logic, to aim to investigate knowledge prior to attempts to know the world is “to seek to know before we know [which] is as absurd as the wise resolution of Scholasticus, not to venture into the water until he had learned to swim”. The commentators then go on to state, in criticism of my essay, that psychopathology is not ‘first philosophy’. To examine, as I do, the “quarrels among phenomenological philosophers about the founding level of phenomenological inquiry” and the possibility of the transcendental reduction, is to burden psychopathology with irrelevant problems. Hence, they write, psychopathologists “can breathe a deep sigh of relief”. I suggest they hold their breath. Psychopathology is not ‘first philosophy’ – I whole heartedly agree with this statement – but in order to establish its basis and validity, phenomenological psychopathology helps itself to the entire Husserlian philosophy, and therein the problem lies.

What is psychopathology? It is a formalisation of abnormal folk psychology : it is the meticulous documentation of mental states and their connections – or lack thereof – and in this sense has no special claim to expertise on mental states except in so far as meticulous documentation can be illuminating. Put differently, psychopathology cannot overstep the soil or ground from which it arises – namely, folk psychology – and claim knowledge of the supposed ‘true’ nature of ‘abnormal’ mental states. But that is precisely what contemporary phenomenological psychopathology wants to do. It is not content with psychopathology being a formalisation of folk psychology and hence dependent on it; it wants psychopathology to be a ‘science’ that exceeds folk psychology and from which the latter can learn. In order for psychopathology to be a ‘science’ it claims a theoretical basis that is not available to folk psychology. It establishes its credentials as a ‘science’ by helping itself to the entire Husserlian philosophy: it helps itself, in particular, to the concept of the ‘transcendental reduction’ without which the proposal for ‘second-order’ empathy as a mode of philosophically articulated understanding of others would not work. (I argued this final point in detail in my essay: achieving second-order empathy requires as a first step that one suspends the natural attitude and grasps that the sense of reality with which experience is ordinarily endowed is a phenomenological achievement, a move which presupposes the possibility of the transcendental reduction.)

Shorn of its theoretical ‘transcendental’ basis, psychopathology falls back to earth as the discipline which meticulously documents mental states and their connections in accordance with the implicit rules and principles of a particular folk psychology (particular since the rules and principles in question are normative and subject to, among other things, the influence of ‘culture’). Psychopathologists may be better in this than others, but that is because they have made it their vocation, and not because they have somehow ventured beyond folk psychology. Indeed, somewhat ironically, the commentators’ own account of how understanding works proves my argument that all we’ve got is ‘first-order’ empathy, of which the qualification ‘first-order’ can now be removed as there is nothing left to contrast it with:

 Jaspers realized that, in order to apply the phenomenological method (in this less demanding sense), I first need to ‘evoke’ the perspective of the other in my own consciousness. This evocation is not some kind of (‘mysterious’) self-immersion into the other’s psyche, but a meticulous and often strenuous (and necessarily imperfect) hermeneutical reconstruction of the other’s mental life (i.e., drawing on my own experiences and elaborate narrations of the pertinent experiences in order to get a ‘feeling’ for the other’s mental life).

Indeed: empathic understanding involves a “hermeneutical reconstruction of the other’s mental life”, a reconstruction in which I draw upon “my own experiences”. It seems then that the commentators’ disagreement with the first part of my essay is not as intractable as it first appeared to be. However, the important point to reiterate is that phenomenological psychopathology faces a dilemma: either it holds fast to its basis in transcendental philosophy and hence becomes theoretically incoherent, or it abandons its pretentions to be a ‘science’ and hence, as indicated, rest content with what it is: a formalised folk psychology. In my view, given the arguments of the original essay, only the latter option is available. And contrary to what it may seem, that is not a bad position to be in; far from it. The documentation of the various states of the mind, their description and the search for connections among them, while that is a vocation that cannot exceed folk psychology, it can certainly make available for the ‘folk’ certain possibilities of human experience and belief of which they were not explicitly aware, and therein its value may lie.

Second critique: ‘Distinguishing methodological from ethical value’

 In the second part of my essay I considered the ethical dimension of the second-order empathic stance. I asked if an attitude which emphasises radical difference – as required by this stance – is the right one to hold towards persons diagnosed with schizophrenia. My answer was that it is not, but the reason why this is so is important and deserves restatement. An attitude which emphasises differences is not the right one to hold, not because such emphasis is bad in itself; I would, for example, consider an attitude which emphasises similarity as also potentially problematic. This is because the issue at stake is not the nature of the attitude, but the degree to which the persons who are at its receiving end have had a say in its construction. The reason such a consideration is normatively significant has to do with the necessity of reciprocal relations of recognition for identity formation and self-realisation. To have an academic discipline launching discourses about others cloaked in the technical jargon of phenomenological philosophy, and possessing of the prestige and authority of scholarly argument in general, is to give those others no real chance and no say in how they would like to be represented. This is not a call to ban certain words or discourses – of course not! But it is a call to appreciate that there is no ethically neutral discourse or methodology. Unfortunately this neutrality is precisely what the commentators seem to be arguing for in critique of the second part of my paper.

They begin by stating that emphasising differences is important as this may ultimately enable the psychiatrist to understand his or her patients:

On the contrary, we assert that psychopathology emphasizes difference in order to encourage the examining psychiatrist to keep on going in the attempt to understand even when such understanding seems to have ‘reached a brick wall’. Examining psychiatrists should keep on going even when they fear that they have hit a limit inherent in understanding the patient.

Now this argument seems to rest on an assumed value being attached to understanding others. They restate their point again as follows:

It is valuable to be aware of the differences of persons with psychotic experiences/schizophrenia and typically ‘‘normal’’ persons, and consequently, to persist in the task of understanding.

They go on to describe the value in question as a ‘methodological’ value and distinguish this from the “ethical value of the person with psychotic experiences/schizophrenia [which] is the same as the ethical value of the rest of us”. I admit I find such a pronouncement somewhat unusual, as it implies that our methodological approaches towards others can be disentangled from our ethical evaluations towards them as long as we insist that they are our equals. If only it was this easy.

Understanding others is not merely of ‘methodological’ value: it is ultimately a core issue in any normative moral theory, and hence much broader. The distinction drawn by the commentators between methodological and ethical value suggests that it doesn’t matter what approaches we adopt towards others as long as we are motivated by understanding them, and never lose sight of the fact that they are our equals. Once seen as a concern with how we should treat others, such a picture appears naïve. For one thing, over and the above the need to understand, lays the wishes of those we are trying to understand: they may wish to have a say in how they would like to be understood, and in the language and method which they consider more representative of who they are. All this is to say that there is no domain of human interaction that lies, as it were, beyond the ethical. Phenomenological psychopathology cannot hide behind this claim to ethical neutrality, irrespective of whether or not it is methodologically valuable.

Mohammed Abouelleil Rashed – May 2015

A Critical Perspective On Second-Order Empathy In Understanding Psychopathology: Phenomenology And Ethics

Article published in Theoretical Medicine & Bioethics 2015

You can find the final version HERE, and the pre-production version HERE

Abstract: The centenary of Karl Jaspers’ General Psychopathology was recognised in 2013 with the publication of a volume of essays dedicated to his work (edited by Stanghellini and Fuchs). Leading phenomenological-psychopathologists and philosophers of psychiatry examined Jaspers notion of empathic understanding and his declaration that certain schizophrenic phenomena are ‘un-understandable’. The consensus reached by the authors was that Jaspers operated with a narrow conception of phenomenology and empathy and that schizophrenic phenomena can be understood through what they variously called second-order and radical empathy. This article offers a critical examination of the second-order empathic stance along phenomenological and ethical lines. It asks: (1) Is second-order empathy (phenomenologically) possible? (2) Is the second-order empathic stance an ethically acceptable attitude towards persons diagnosed with schizophrenia? I argue that second-order empathy is an incoherent method that cannot be realised. Further, the attitude promoted by this method is ethically problematic insofar as the emphasis placed on radical otherness disinvests persons diagnosed with schizophrenia from a fair chance to participate in the public construction of their identity and, hence, to redress traditional symbolic injustices.

Mohammed Abouelleil Rashed   2015

Islamic Perspectives on Psychiatric Ethics

My chapter published online at Oxford Handbooks.

Will appear in print in the Oxford Handbook for Psychiatric Ethics Volume 1 next year.


Islamic Perspectives on Psychiatric Ethics explores the implications for psychiatric practice of key metaphysical, psychological, and ethical facets of the Islamic tradition. It examines: (1) the nature of suffering and the ways in which psychological maladies and mental disorder are bound up with the individual’s moral and spiritual trajectory. (2) The emphasis placed on social harmony and the formation of a moral community over personal autonomy. (3) The sources of normative judgements in Islam and the principles whereby ethical/legal rulings are derived from the Qur’an and the Prophetic Traditions. Finally, the perspective of the chapter as a whole is employed to present an Islamic view on a number of conditions, practices, and interventions of interest to psychiatric ethics.

Click HERE for Pre-Production version