The Meaning of Madness

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Excerpt from Chapter 1 of my book “Madness and the Demand for Recognition”. Forthcoming with Oxford University Press, 2018

Mad with a capital m refers to one way in which an individual can identify, and in this respect it stands similar to other social identities such as Maori, African-Caribbean, or Deaf. If someone asks why a person identifies as Mad or as Maori, the simplest answer that can be offered is to state that he identifies so because he is mad or Maori. And if this answer is to be anything more than a tautology – he identifies as Mad because he identifies as Mad – the is must refer to something over and above that person’s identification; i.e. to that person’s ‘madness’ or ‘Maoriness’. Such an answer has the implication that if one is considered to be Maori yet identifies as Anglo-Saxon – or white and identifies as Black – they would be wrong in a fundamental way about their own nature. And this final word – nature – is precisely the difficulty with this way of talking, and underpins the criticism that such a take on identity is ‘essentialist’.

Essentialism, in philosophy, is the idea that some objects may have essential properties, which are properties without which the object would not be what it is; for example, it is an essential property of a planet that it orbits around a star. In social and political discussions, essentialism means something somewhat wider: it is invoked as a criticism of the claim that one’s identity falls back on immutable, given, ‘natural’ features that incline one – and the group with which one shares those features – to behave in certain ways, and to have certain predispositions. The critique of certain discourses as essentialist has been made in several domains including race and queer studies, and in feminist theory; as Heyes (2000, p. 21) points out, contemporary North American feminist theory now takes it as a given that to refer to “women’s experience” is merely to engage in an essentialist generalisation from what is actually the experience of “middle-class white feminists”. The problem seems to be the construction of a category – ‘women’ or ‘black’ or ‘mad’ – all members of which supposedly share something deep that is part of their nature: being female, being a certain race, being mad. In terms of the categories, there appears to be no basis for supposing either gender essentialism (the claim that women, in virtue of being women, have a shared and distinctive experience of the world: see Stone (2004) for an overview), or the existence of discrete races (e.g. Appiah 1994a, pp. 98-101), or a discrete category of experience and behaviour that we can refer to as ‘madness’ (or ‘schizophrenia’ or any other psychiatric condition for this purpose). Evidence for the latter claim is growing rapidly as the following overview indicates.

There is a body of literature in philosophy and psychiatry that critiques essentialist thinking about ‘mental disorder’, usually by rebutting the claim that psychiatric categories can be natural kinds (see Zachar 2015, 2000; Haslam 2002; Cooper 2013 is more optimistic). A ‘natural kind’ is a philosophical concept which refers to entities that exist in nature and are categorically distinct from each other. The observable features of a natural kind arise from its internal structure which also is the condition for membership of the kind. For example, any compound that has two molecules of hydrogen and one molecule of oxygen is water, irrespective of its observable features (which in the case of H2O can be ice, liquid, or gas). Natural kind thinking informs typical scientific and medical approaches to mental disorder, evident in the following assumptions (see Haslam 2000, pp. 1033-1034): (1) different disorders are categorically distinct from each other (schizophrenia is one thing, bipolar disorder another); (2) you either have a disorder or not – a disorder is a discrete category; (3) the observable features of a disorder (symptoms and signs) are causally produced by its internal structure (underlying abnormalities); (4) diagnosis is a determination of the kind (the disorder) which the individual instantiates.

If this picture of strong essentialism appears as a straw-man it is because thinking about mental disorder has moved on or is in the process of doing so. All of the assumptions listed here have been challenged (see Zachar 2015): in many cases it’s not possible to draw categorical distinctions between one disorder and another, and between disorder and its absence; fuzzy boundaries predominate. Symptoms of schizophrenia and of bipolar disorder overlap, necessitating awkward constructions such as schizoaffective disorder or mania with psychotic symptoms. Similarly, the boundary between clinical depression and intense grief has been critiqued as indeterminate. In addition, the reductive causal picture implied by the natural kind view seems naive in the case of mental disorder: it is now a truism that what we call psychiatric symptoms are the product of multiple interacting factors (biological, social, cultural, psychological). And diagnosis is not a process of matching the patient’s report with an existing category, but a complicated interaction between two parties in which one side – the clinician – constantly reinterprets what the patient is saying in the language of psychiatry, a process which the activist literature has repeatedly pointed out permits the exercise of power over the patient.

The difficulties in demarcating health from disorder and disorders from each other have been debated recently under the concept of ‘vagueness’; the idea that psychiatric concepts and classifications are imprecise with no sharp distinctions possible between those phenomena to which they apply and those to which they do not (Keil, Keuck, and Hauswald 2017). Vagueness in psychiatry does not automatically eliminate the quest for more precision – it may be the case, for example, that we need to improve our science – but it does strongly suggest a formulation of states of health and forms of experience in terms of degrees rather than categorically, i.e. a gradualist approach to mental health. Gradualism is one possible implication of vagueness, and there is good evidence to support it as a thesis. For example, Sullivan-Bissett and colleagues (2017) have convincingly argued that delusional and non-delusional beliefs differ in degree, not kind: non-delusional beliefs exhibit the same epistemic short-comings attributed to delusions: resistance to counterevidence, resistance to abandoning the belief, and the influence of biases and motivational factors on belief formation. Similarly, as pointed out earlier, the distinction between normal sadness and clinical depression is difficult to make on principled grounds, and relies on an arbitrary specification of the number of weeks during which a person can feel low in mood before a diagnosis can be given (see Horwitz and Wakefield 2007). Another related problem is the non-specificity of symptoms: auditory hallucinations, thought insertion, and other passivity phenomena which are considered pathognomonic of schizophrenia, can be found in the non-patient population as well as other conditions (e.g. Jackson 2007).

Vagueness in mental health concepts and gradualism with regards to psychological phenomena undermine the idea that there are discrete categories underpinned by an underlying essence and that go with labels such as schizophrenia, bipolar disorder, or madness. But people continue to identify as Women, African-American, Maori, Gay, and Mad. Are they wrong to do so? To say they are wrong is to mistake the nature of social identities. To prefigure a discussion that will occupy a major part of Chapters 4 and 5, identity is a person’s understanding of who he or she is, and that understanding always appeals to existing collective categories: to identify is to place oneself in some sort of relation to those categories. To identify as Mad is to place oneself in some sort of relation to madness; to identify as Maori is to place oneself in some sort of relation to Maori culture. Now those categories may not be essential in the sense of falling back on some immutable principle, but they are nevertheless out there in the social world and their meaning and continued existence does not depend on one person rejecting them (nor can one person alone maintain a social category even if he or she can play a major role in conceiving it). Being social in nature they are open to redefinition, hence collective activism to reclaim certain categories and redefine them in positive ways. In fact, the argument that a particular category has fuzzy boundaries and is not underpinned by an essence may enter into its redefinition. But demonstrating this cannot be expected to eliminate people’s identification with that category: the inessentiality of race, to give an example, is not going to be sufficient by itself to end people’s identification as White or Black.

In the context of activism, to identify as Mad is to have a stake in how madness is defined, and the key issue becomes the meaning of madness. To illustrate the range of ways in which madness has been defined, I appeal to some key views that have been voiced in a recent, important anthology: Mad Matters: A Critical Reader in Canadian Mad Studies (2013). A key point to begin with is that Mad identity tends to be anchored in experiences of mistreatment and labelling by others. By Mad, Poole and Ward (2013, p. 96) write, “we are referring to a term reclaimed by those who have been pathologised/ psychiatrised as ‘mentally ill,'”. Similarly, Fabris (2013, p. 139) proposes Mad “to mean the group of us considered crazy or deemed ill by sanists … and are politically conscious of this”. These definitions remind us that a group frequently comes into being when certain individuals experience discrimination or oppression that is then attributed by them as arising from some features that they share, no matter how loosely. Those features have come to define the social category of madness. Menzies, LeFrancois, and Reaume (2013, p. 10) write:

Once a reviled term that signalled the worst kinds of bigotry and abuse, madness has come to represent a critical alternative to ‘mental illness’ or ‘disorder’ as a way of naming and responding to emotional, spiritual, and neuro-diversity. … Following other social movements including queer, black, and fat activism, madness talk and text invert the language of oppression, reclaiming disparaged identities and restoring dignity and pride to difference.

In a similar fashion, Liegghio (2013, p. 122) writes:

madness refers to a range of experiences – thoughts, moods, behaviours – that are different from and challenge, resist, or do not conform to dominant, psychiatric constructions of ‘normal’ versus ‘disordered’ or ‘ill’ mental health. Rather than adopting dominant psy constructions of mental health as a negative condition to alter, control, or repair, I view madness as a social category among other categories like race, class, gender, sexuality, age, or ability that define our identities and experiences.

Mad activism may start with shared experiences of oppression, stigma and mistreatment, it continues with the rejection of biomedical language and reclamation of the term mad, and then proceeds by developing positive content to madness and hence to Mad identity. As Burstow (2013, p. 84) comments:

 What the community is doing is essentially turning these words around, using them to connote, alternately, cultural difference, alternate ways of thinking and processing, wisdom that speaks a truth not recognised …, the creative subterranean that figures in all of our minds. In reclaiming them, the community is affirming psychic diversity and repositioning ‘madness’ as a quality to embrace; hence the frequency with which the word ‘Mad’ and ‘pride’ are associated.

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The Dakhla Oasis: Stories from the ‘field’ (0)

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Arrivals

The road from Kharga is an isolated strip of asphalt winding through arid desert that alternates between flat, uneventful plains and more spectacular sand-dunes. Seventy kilometres before you arrive to the village of Mūt, the landscape bursts with numerous shades of pastel colours: the desert alternates with lush vegetation, plain fields, and palm tree groves bounded on the Northern side by a mountain chain and on the Southern side by more flat desert. Several villages dot the remainder of the road, some tucked in the bosom of the mountain and barely visible and others, like Asmant, start right at the road and sprawl into the distance. A few villages later the vegetation is overtaken by the low-lying buildings of Mūt; a curious mix of half-completed one and two-storey concrete buildings and traditional mud brick dwellings. This is the largest village in Dakhla, the Inner Oasis and the third most populated in the Western desert.

Oases of the Western Desert: An Historical Snapshot

Extending west of the Nile-valley and occupying two thirds of the land surface of Egypt, the Western Desert – otherwise an arid expanse of over 680,000 square kilometres – is dotted by six depressions: the oases of Siwa, Fayyoum, Bahariyya, Farafra, Dakhla, and Kharga. Beyond the Western political border of Egypt, it becomes the Libyan Desert, and shortly after merges in with the Sahara. With Cairo as a reference point, Fayyoum is the closest, largest and most populated of the six oases. Siwa lies only 50 km east of the Libyan border and, traditionally, has been the most isolated. The other four oases lie on an arc that starts at Cairo, curves West into the desert and 1330 km later returns to the Nile-valley at Luxor. Farafra lies at the Western-most point of that arc, followed by Dakhla.

According to the 2006 national census, the population of the locality of Dakhla is 79,812 (CAPMAS 2007). This is the total population of each locality including the main town, Mūt, and the many villages surrounding it. The oases have seen a significant population boost over the past few decades. Throughout its history, however, the population of the oases tended to fluctuate dramatically for reasons to do with diminishing water supplies and the ever-present danger of Bedouin raids.

What we know from archaeological remains is that Dakhla has seen human activity since Palaeolithic times (Kubiak and Zabowski 1995, 10). In the Pharaonic period, Egyptians from the Nile-valley appear to have arrived at Dakhla in 2300 BC (Mills 1999). Ohat R’seit – the Southern Oasis – was part of the same administrative division as the oasis of Kharga, and evidence indicates that the responsible authority sought to maintain and develop the oases primarily as a first line of defence against incoming raids from the West and South (Abu-Zayd 1997). Papyri from the Graeco-Roman period indicate that Dakhla was governed through a tight organisational structure, with the population mainly of Libyan Berber origin and engaged in agriculture (Wagner 1987). Prior to the introduction of Christianity, religion was a form of paganism; late Egypto-Hellenic syncretism. The Roman period is considered to have been unusually prosperous for the oases but at a price. Intensive farming and the use of new irrigation techniques have, as Thurston wrote, “sucked the oasis dry of easily accessible water” and meant that during the Byzantine period, Dakhla was “unable to provide more than a subsistence living for a greatly reduced and declining population” (2003, 320). That did not preclude the spread of Christianity to the oases, with evidence of dominant Christian presence persisting up till the 10th century; four centuries after the Arab (Muslim) conquest of Egypt.

By 644 AD the Arabs had already conquered all of Arabia, Syrian and Egyptian parts of the Byzantine Empire, and parts of Persia. The decline of the oases in later Roman and Byzantine empires continued into the first few centuries of Arab rule: wells were not maintained, and the population were offered no protection against Bedouin raids, which resulted in immigration to safer areas and a relative depopulation of the oases between the 11th and 15th centuries (Fakhry 2003; Beadnell 1909). By the 14th and 15th centuries (towards the end of Mamluk rule) the oases experienced a second period of prosperity. The outcome of this period has been likened to that of its earlier Roman equivalent in that the extensive use of water was not accompanied by a concern for the “long-term consequences for the residents or the productivity of the land itself” (Thurston 2003, 324; see also Keall 1981). It was during this period that the medieval walled city of El-Qasr would be built in Dakhla. It survives to this day, unlike the similarly named city in Farafra which collapsed after heavy rains in 1945. Here is Thurston describing El-Qasr in Dakhla:

Heavy acacia gates divided the city into neighbourhoods, each of which would have been the precinct of a tribe-based clan. The gates were locked at night, as were the main city gates, against the threat of raids, which continued into the 19th c. (2003, 323).

The Ottoman conquest of 1517 signalled the end of Mamluk rule in Egypt. The three centuries that followed witnessed a decline in farming areas and the oases were not spared. They were also three centuries with no information on the oases, a fact that has been linked to the general cultural decline in Egypt under Ottoman rule (Kubiak and Zabowski 1995). It was only with the rise of European exploration by the early 19th century that the oases began to be mentioned again in various topographical and geological works. Absent from the work of these explorers, which is perhaps expected considering their interests, are consistent observations or accounts of social and cultural life in the oases. And in the case where such accounts exist, as in W. J. Harding King’s (1925), they take the form of travelogues with superficial observations that would now seem to us ethnocentric and biased, if not racist. The paucity of historical material has only been partly rectified by Ahmed Fakhry, the first Egyptian Egyptologist. Fakhry (2003) visited Farafra and Bahariyya several times between 1938 and 1968 and wrote in an informal style about archaeological findings as well as brief comments on life in the oases.

In 1938, according to Fakhry, the only link between Farafra and the neighbouring oases (Bahariyya and Dakhla) was a four day camel trip. There were no modern means of communication or any form of “mechanized transport”. There was no electricity, and in the whole oasis only three watches existed. Houses, as Fakhry described them, were similar in form to those found on the edges of cultivated areas in the Nile-valley: a central courtyard with a dwelling in one corner, a small garden and a well. The inhabitants, he observed, had a different dialect to those of Bahariyya and Dakhla, a fact he attributed to their Bedouin blood. They were more religious and stricter than their neighbours; women did not mix with strangers, unlike in Bahariyya, which had been a place of forced exile for Siwan women accused of adultery. He described a total absence of what he called “European clothing” in 1938, but by 1968 teachers and the few government officials in the oasis could be seen in trousers and coats. This seemingly minor observation, however, was an indication of significant changes that began to happen in the oases of the Western desert. The “new-valley project” had already been conceived by the Egyptian government, and it was only a few years into the project, and as he was leaving Farafra in 1968 that he wrote:

I thought of the rapidly changing life in the oasis and wondered how long the inhabitants could keep their old traditions alive. The concept of bringing several thousand immigrants here from the Nile Valley when the new irrigation projects opening (sic) thousands of feddans take place, saddened and distressed me. Will the honest, peaceful citizens of Farafra be pushed into a corner by the new, aggressive immigrants, as has happened in Kharga? (2003, 180)

The New-Valley Project

Land reclamation in the Western desert began in the 1960s under the guidance of President Gamal ‘Abdel-Nasser. The idea was to counter overpopulation in the Nile-valley by reclaiming desert land, creating new villages, and boosting agricultural production (Gudowski and Raubo 1995). The Western desert was seen as a land of opportunity that could potentially solve the problems of a “new Egypt” freed of British and Monarchic rule and set to modernise and develop:

Escaping the confines of the narrow and over-populated Nile-Valley into the wide expanse of Egypt’s land is the only way to build a future for Egypt, by absorbing the increasing population, and opening wide horizons for development and progress (Abu-Zayd 1997, 17).

Throughout the 60s and 70s hundreds of wells were dug, bringing to the surface millions of cubic metres of the non-renewable fossil water under the desert (Thurston 2003). Roads were built connecting the four oases with the Nile-valley (Kuzak 1995, Mills 1999). The project slowed down during the two wars with Israel and the six years in between (1967 to 1973) and large scale reclamation properly began in the 1980s. Despite intense development, the New-valley project did not fulfil the grand ambitions of the Egyptian government which included an estimated post-reclamation population of 2 million (current population of the area originally included in the project is 210,352 (CAPMAS 2007)). Part of the reason was the expense of land reclamation and the reluctance of Egyptians to leave the Nile-valley for the desert. Concerns about the falling water table further slowed down the digging of new wells. The water situation is such that unless alternative projects for transporting water from the Nile succeed, the water under Dakhla oasis could be depleted in 50 years, in which case the oasis will gradually cease to exist (Thurston 2003).

A recent document issued by the State Information Service entitled ‘New-Valley Panorama’ (Abu-Zayd 1997) acknowledged that development in the New-Valley has not fulfilled the “dreams” of Egyptians and has failed to mine the huge potential of the region. Mubarak’s government has been attempting since the mid-nineties to rectify this situation by constructing a canal, the ‘New-Valley Canal’, which carries Nile water from Lake Nasser south of the country for a distance of 850 kilometres passing by Uweinat, Kharga, Dakhla and terminating in Farafra. The grand plan is not just land reclamation but the construction of eighteen new towns, a hundred industrial sites, and a number of tourism projects. The ultimate goal is to build “a new civilisation, parallel to that of the old [Nile] Valley”. This project has met immense technical difficulties, not least due to the intense heat in this part of Egypt which salinates the water before it can cover a fraction of the intended distance; the reliance on underground water continues.

Dakhla Today

Today, Dakhla is a major oasis with 33 villages and an urban centre, Mūt, with a population of ten thousand. Agriculture remains the main activity, although the inhabitants supplement their income through various other means. All families own land and the men usually rotate tending for it. Prior to the New-Valley project the local leader, the ‘Umda, controlled most of the land and was the one who rented and sold to others. In the sixties this changed, and the government started digging wells and offering local families and immigrants 5 feddans and a cow for symbolic prices. If a family are particularly well-to-do they could dig their own well, otherwise they must rent water from the government for a symbolic fee of forty Egyptian pounds a year.

Water is rarely owned by a single family, and a well is shared among several plots of land. Owners must observe a specific water rota, and intentional or inadvertent violations of the rota may lead to problems which are usually resolved locally and very rarely involve the police. When a well dries and the family cannot afford to dig deeper or buy a bigger pump to pull the water, the owners must accept the slow death of their land. Land owned by families tends to be small, and the families grow less for profit and primarily for subsistence. Many families own livestock kept in a shed on their plot of land. Once a year they may sell a cow which would bring about 4000 to 6000 Egyptian pounds.

Contrasting with the small plots of lands that locals own, the government has been offering areas of up to thousands of Feddans for investment. Huge plots of land, in Uweinat and to a lesser extent Dakhla, have been bought by Egyptian and foreign investors who have launched major projects with the sole purpose of profit. Occasionally I saw huge trucks passing through Mūt and carrying produce straight to Suez and Alexandria for export. These projects are subject to modern irrigation standards in order to reduce water loss. Recently the government began to interfere in what the families could grow. Rice was banned a few years ago in view of the huge water waste involved in growing it. This has been met with disdain by the locals who are big rice eaters and must now buy it at a greater expense from Asyut, the nearest city. Concerns regarding the water supply do not strike a chord here. Most people reject the scientific evidence that underground water is non-renewable, and many argue that water is replenished directly from the Nile. The government’s grand project of the ‘New-Valley canal’ is branded as mere propaganda. The water issue for the people of Dakhla is a financial issue: enough money means more wells, and pumps that can bring water from deeper levels.

The fact remains, if you exclude a few families, that agriculture on its own cannot be the sole financial sustenance. Many men and women are employed as civil servants in the various government institutions that accompanied the development of the region. These positions are sought for the consistent income they offer and the guarantee of a pension. Otherwise people get by through working in multiple jobs. A man will work as a civil-servant in the morning and tend the land in the evening or early in the morning before heading off to work. Trading in livestock, running a shop or a coffee-house, or driving a micro-bus are all common sources of income. Tourism is not as big as in Bahariyya or Farafra, and consists mainly in arranging safaris for European tourists to the Great Sand Sea and El-Gilf Al-Kabeer. Free time is rare amid multiple jobs, and the few free hours of the day are spent at the coffee-house or at home. The reality remains, however, that the land must be preserved and tended regardless of any other jobs a man takes on. A father expects his sons to take over the land from him as he grows older.

Despite the constant struggle to make ends meet, many of the older inhabitants – those who recall life in the fifties – acknowledge the significant improvements brought by the New-Valley project. Back then food was scarce, and the absence of electricity constrained the range of edible foods to what could be dried and stored safely. The scarcity of water required that vegetables and fruit be brought from Asyut on desert tracks at huge expense. The construction of roads linking the oasis with the Nile-Valley meant that more people could travel to Asyut and Cairo to seek work and send money back to their families. More recently, some men have taken to economic migration to Kuwait and Saudi-Arabia to the detriment of the land they leave behind for their neighbours to tend. However the New-Valley project resulted in a huge surge of immigrants, mostly men, descending on the oasis. Up to this day the inhabitants of Dakhla clearly distinguish between themselves – the natives – and the immigrants. Families who have lived in the oasis for over fifty years are still considered outsiders, and even though they have married local women, the preference remains to “give your daughter in marriage” to a local.

Up to, perhaps, two decades ago the old-town represented the physical boundary of the villages. Within its high gates the inhabitants lived, stored their grain, married, died and, when required, sought protection from marauding Bedouins and others. Today the old-town no longer fulfils its historic role since the majority of the population have descended to the plains below, leaving the old-town to crumble in disrepair. In any case it would not have accommodated the population increase, which perhaps explains why people in the villages continue to live in mud-brick houses. A few families continue to live in El-Kharaba (the ruins, and the name given to the crumbling old-town), and those who have moved out continue to use their old houses for storage of chickens and pigeons. Today, El-Kharaba is a cornucopia of interlocking dwellings and shaded corridors and mazes that form an asymmetrical, organic mass with a fluid horizontal and vertical perspective. The houses, which are entirely made of mud-bricks, palm reeds, and natural wood, are now mostly in ruins, although you can still see the occasional standing house in perfect condition with electric lights and a satellite dish on top. The ruins also lend themselves to more ominous uses: drug users and seekers of illicit sex frequent the ruins at night unmoved by the inherent dangers of being caught or the risk of unsettling evil spirits that tend to inhabit deserted spots.

The descent from Old Mūt to the plains below occurred gradually over a twenty year period, although some families do not want, or cannot afford, to leave their mud-brick house for a concrete one. My friend Tariq told me that the first concrete building in Mūt was raised about thirty years ago and was a government site. When I asked him when he moved out of the old-town he paused and said: “you can only extend your feet as far as your covers go”. They’ve moved out only three years ago and this, in Mūt, is very recent. Moving out of the old-town has acquired status significance over the years: everyone is expected to want to build and live in a concrete house. Even though people complain about the concrete houses – the manner in which they lock-in the heat unlike the mud-brick dwellings which are cool in the middle of summer – the majority agree that modern houses are more comfortable and require less maintenance.

The concrete and steel construction surge that accompanied the descent from Old-Mūt still shows no sign of abating. All over town you see one and two-floor storey buildings with concrete pillars jutting out of the roofs and exposed bare steel rods rising upwards, the whole construction eerily resembling a helpless upturned insect. Such constructions are scattered all over town, giving the place the feel of a perpetually developing building site. Later when I understood the economics and pragmatics of house construction I appreciated why all the houses must have these unsightly pillars and steel rods jutting out of them. These pillars stand testament to deficient funding and the intention of “raising another floor”. Families in Dakhla continue to live together. Whereas the older mud-brick dwellings were organised around a central court-yard surrounded by several rooms – one for each family, the newer concrete houses allow more privacy, since each family lives in a separate flat. Brothers tend to share a house and as they approach the marriage age and once a few thousand pounds are amassed, concrete and steel can be bought from Asyut and a further floor could be built. Fathers build for their sons, while daughters usually move in with their husband’s family.

Perhaps the best spot to observe Mūt is from the top of El-Kharaba. Up there you could see concrete buildings stretching all the way to the green fields, beyond which the desert and mountains start. Most of the buildings have the obligatory steel rods dangling upwards; few are painted from the outside, and are built of manufactured red-bricks. The amorphous brown mass that is old Mūt gives way to a chaotically arranged red mass of houses occasionally interspersed by palm tree groves until, finally, it gives way to the fields proper and then the desert. From this vantage point Mūt is a simple collage of four colours: Brown, Red, Green, and Yellow. The colours of the naturally sourced material that comprise the substance of the mud-brick dwellings blend in seamlessly with the green fields and the yellow desert, but the New Mūt with its manufactured red-bricks and steel rods breaks this harmony.

In addition to agriculture, work, and housing, modernisation has touched other elements of life in the oasis. The literacy rate here is one of the highest in the country (81.2%). There are several primary and secondary schools in Mūt alone, although seekers of higher education must head to Kharga or further to Asyut and Cairo. Secondary education may take one of two routes: the conventional academic route that allows the graduate to go to university, and the more common route of specialised education where the students are trained in a practical discipline of their choice: agricultural, industrial, religious or commercial.

Technology has taken on in the oasis rather quickly. Mobile phones are ubiquitous since their introduction nine years ago. Television and electricity were introduced in 1982, and satellite dishes made an appearance in the past seven years. Whether at home or at the coffee-houses people spend significant time watching Egyptian, Indian and foreign films as well as American wrestling which is extremely popular with the men here. A number of religious channels offer an alternative for the more conservative. There are a few internet cafes and it remains quite rare for a family to have their own connection at home, primarily because personal computers are still quite expensive. People in Dakhla remain ambivalent about the effects of technology on society. A primary school teacher complained that children are no longer as focused at school; they are distracted by what they see on the Internet. Mobile phones are blamed for limiting family visits; prior to their introduction visits among the extended family would happen at least once a week and now people suffice with a phone call. Elders blame television for changing people’s expectations regarding marriage: “The youth now want to fall in love and live in their own separate apartments; they are copying what they see in the Egyptian [read: Cairene] serials and films”.

Health care has also seen significant infrastructural development. Mūt has a central hospital with several medical and surgical specialties in addition to an accident and emergency department, although they have no psychiatry or neurology departments. There are a number of private clinics and two private hospitals. The consensus here is that doctors in Mūt are largely incompetent. Seriously ill individuals are frequently taken to Asyut, 600 kilometres away, where there is a teaching hospital with well-known specialists. Otherwise healers are consulted for a wide range of problems, including those which medical doctors would recognise as falling within their domain.

This sketch of the major changes that accompanied the inception of the New-Valley project shows that Dakhla in the first decade of the 21st century is a different place from what it was prior to the sixties. Elements of modernisation have touched all people’s lives, extending to the intimate areas of speech and dress. Under the influence of immigrants, television and local teachers (many of whom are from the Nile valley) the Dakhlan dialect is now all but absent, increasingly resembling the Cairene dialect, a fact that Woidich (2000) already observed towards the end of the 90s. Local dress is largely indistinguishable from that in the rest of Egypt, even among older women whom Rugh (1987) noted were the final preservers of traditional dress. These changes are most evident in Mūt which I find accurate to describe as an urban centre with a village feel. The changes which started rather abruptly about forty-five years ago have affected people’s lives, creating new problems and opportunities and constituting specific identities.

Cairo 2010

The Dakhla Oasis: Stories from the ‘field’ (I)

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Marriage and Reputation

Tariq lives with his mother in a concrete house in the old part of town. They moved out of El-Kharaba only three years ago, a fact that he declares with slight embarrassment. A month ago his wife and three year old daughter would have been living with them, but they had fallen out and she moved in with her elder brothers; he remains reluctant to bring her back home. I first met Tariq at the coffee house at El-Midan (the square dominating the old part of Mūt); we instantly became friends. Tariq’s day starts at seven in the morning: he cycles to the government site where he rents out tractors and loaders by the hour. Like most civil-servants, he is expected to sign-in at eight-thirty in the morning and not to leave before two in the afternoon, and like many government employees he tries to negotiate this in order to have more time “earning his keep” through various other jobs.

Like most men in Dakhla, Tariq shares the responsibilities of the land with his brothers. A few days a week he has water duties which involve moving around the panels that regulate water supply to guarantee that others have their share. On Sunday and Thursday evenings he coaches table tennis at a modest ‘youth centre’ on the edge of town, a feat that involves a few informal strokes with high school students interspersed by several cigarette breaks. On Friday and Saturday mornings, his days off, he works a shift at a coffee-house that belongs to his friend, ‘Ali. I frequently accompanied Tariq to the fields helping him with the water, to the youth-centre for a few informal table tennis strokes, and on those early week-end mornings I joined him at the coffee-house where I would prepare my Turkish coffee and utilise the rarity of patrons to chat with him. On one such morning I first learnt that he had been married once before.

It would be hard to overestimate the importance of marriage. In my first week of field work I attended Friday prayers at the “big mosque”. The topic of the sermon was marriage and the imam was listing its benefits: “to marry is to complete your religion; marriage is half your faith. It provides you with companionship and offspring. It is the natural progression of life”. For the men and women of Mūt it is frequently their only sexual outlet. Hussein, a resident of the village of Asmant, told me when I visited him to talk to his mentally unwell and unmarried sister, Fayza, that spinsterhood is a mosiba (disaster).

Tariq’s first marriage was not consummated; they signed the contract but she continued living at her father’s house. Tariq was not pleased with her conduct: she did not ask his permission before leaving the house, she met her brother-in-law with her hair uncovered,[1] and on occasion he saw her conversing with male cousins and relatives in the street. Tariq did not receive the expected support when he approached her father complaining of his daughter’s conduct. “Until you’ve entered,”[2] he told him, “the final word remains with me”. Tariq refused to accept this and his mind was set on divorce but not before “teaching her a lesson” and leaving her “hanging for a few weeks”. He stopped visiting them at home, cut all contact, and took no steps towards a divorce. The bride’s family contacted his mother urging her to convince her son either to return or to divorce their daughter, and not to leave her in this disgraceful situation. “Don’t give them a reason to hurt us”, Tariq recalls his mother warning of the possibility of retaliatory magic: “divorce her now, and find another woman who can make you happy”. He finally complied.

A couple of years later he married his cousin and had a child with her. She moved in, as custom dictates, with him and his mother. Over the few years of their marriage it became apparent that they did not get along well. Their life was dominated by frequent quarrels, disagreements and fights usually over trivial matters. Sayyed, Tariq’s friend, believes their personalities do not match: “they are both hot-blooded”. On several occasions she would leave the family home and return to her brothers, only this last time he vowed not to make any effort to get her back. Despite reconciliatory interventions by her brothers he remains reluctant. “The very act of leaving the house like this,” he told me once, “is unforgivable; here it’s a big thing and could lead to divorce”. Both Tariq and Sayyed think the situation would have been different if her father was alive: “no one in the family has the authority to tell her to return home; this is something the father should be involved in”. A common story, one that I have heard several times and which I finally learned refers to Sayyed’s second cousin, drives the point home:

My relative has been having problems with her husband and returned to her father’s house. She asked for a divorce, and a meeting was arranged. I was there, and the father, brother and husband. The father asked his daughter: ‘I will divorce you from him right now, if you can do one thing: strip naked here in front of us’. The girl was shocked, and couldn’t understand why her father was saying this. Then he suddenly stood up and tore the dress off her. The girl, screaming, ran to her husband and took cover in his arms. The father then looked at her and said: ‘Your husband, and not me or your brother, is your satr [shelter/protection]; you must return with him.

His wife’s brothers, who also happen to be his cousins, played a role. One of them urged Tariq to treat her gently, to take her out for walks more frequently so she does not feel “suffocated” at home. Another, who happens to be more conservative, was opposed to the idea of divorce since it is religiously permissible but discouraged (abghad el-halal). The third raised the possibility that someone, probably the estranged first wife or her family, had sought a magician to prepare an ‘amal (hex) to separate them; the infamous ‘separation magic’. In fact, he had taken steps and visited a magician who confirmed the above and requested to see Tariq. I asked him in the presence of Sayyed whether he would go: “I don’t want to go down this route; its haram (prohibited), we must always refer back to Islamic teaching and engaging in magic is haram”. I said he would not be engaging in magic, only undoing it but he was not convinced: “the magician is probably a charlatan”. Sayyed interrupted him saying that magic is mentioned in the Qur’an and definitely exists. He suggested consulting a Qur’anic healer: “go to Sheikh Rayyes and he will read on you, there is nothing haram with that!” Tariq refused all our suggestions. At this point Sayyed looked at me and said: “he has decided, he doesn’t want her, he wants to change, it’s been three years now and he is bored; we shouldn’t try and solve the problem, we should find him a new wife”. Tariq was silent, but smiled at us meaningfully, a smile of complicity.

 That Tariq should be bored is not surprising. Excepting minor and infrequent youthful, sexual skirmishes most men here first encounter sex on their wedding night. Frequently their spouse would be the only sexual partner they will ever have. He once told me that the novelty of sex with your wife dissipates even after the first time. I half-jokingly suggested mot’a marriage,[3] but was told that marriage in Dakhla is no longer that simple; the bride’s parents always ask for an apartment and mahr (dowry). “In the old days”, Tariq explained, “it was halal [permitted] to sleep with maids that worked at your residence, but we can’t do this now; slavery is finished”. This narrows down his options to a second marriage. According to Islamic law a man can marry up to four women but only under strict criteria which include that his first wife must know and agree; if she does not she has a right to an immediate divorce. Tariq’s predicament is complicated by the fact that he does not wish to divorce his wife, yet remains obliged to declare his intention to marry a second time, upon which she will certainly ask for a divorce. A divorce will complicate several things for him: his rights to see his daughter, financial obligations, and it will constitute a blow to his reputation: a man who has been divorced twice is hardly eligible marriage material.

Divorce and second marriages remain rare in Dakhla, and in the absence of obvious and pressing legitimating reasons are frowned upon. This was apparent in the response to Hajj Sa’ad’s marriage to a twenty-four year old girl from Kafr El-Shiekh, one of the Nile-Delta governorates. Hajj Sa’ad is in his late forties and has been married for the past twenty-five years to a lady known for her good manners and religiosity; no one could understand why he would bring her another woman. I joined him and a friend once at the coffee-house. His friend was reprimanding him for marrying a second time: “since your marriage a month ago, people in town have been infuriated”. Hajj Sa’ad reasoned with him: “people don’t know the circumstances; she wasn’t taking good care of my mother who is an old woman now, what am I supposed to do? And my children are older and busy with their life. I told her I will marry another woman and I gave her the choice; she could ask for a divorce, or stay in the house with us, or I could get her a flat and move the furniture into it. She asked to move out but didn’t mention the divorce. And now two weeks later I get a letter from court saying she wants to terminate our marriage”.

In any case the reputation of Hajj Sa’ad, a man who has sustained a marriage for over twenty years, will not be affected that much by his decision to marry again, but this is not so for a young man like Tariq or indeed for young men in general. Reputation in Dakhla, for men and women alike, is a fragile attribute, subject to various factors that may elevate or reduce ‘it’. A positive reputation in men involves desirable traits such as generosity and kindness to parents, pre-marital celibacy in addition to financial ability. In women, virginity is paramount and contact with other men problematic. With both sexes, physical integrity, mental stability, and absence of chronic illness are crucial. This is Mahdi, a twenty-six year old chicken and vegetable trader, telling me about a potential bride:

A few months ago I was attracted to this girl who works at a shop by the hospital. Day by day I noticed that every time I pass by her house on my way home and she would be standing outside she would immediately run inside. I met her at the shop and asked her why she runs away every time she sees me, have I done something wrong? She said she does that with any man passing by the house. I liked that. I went to speak with her mother and told her that I am interested in her daughter, and we agreed that we will get to know each other for a short time by talking on the mobile phone before informing the father or anyone else about my intention to marry her. This is more common now, although not everyone does it. It’s not like the old days where you wouldn’t have spoken to the bride at all. Its better this way; if we find that we are not compatible then things end without the whole town knowing about it, and so they don’t count another engagement on us. As the engagements pile on you, any future family will demand to know why the engagements failed and you could develop a reputation around town that you are a difficult, unstable person. It’s worse for the woman. It’s not like Egypt [Cairo], where you could get engaged without the whole town knowing; here news travels immediately, and your reputation is always at stake.

A few weeks later he formally proposed and the father followed the customary procedure of “asking around” about him. Fortunately for Mahdi, he is neither involved in drug use, nor is he indolent; a “hard-working, honest man” is how he describes himself. The engagement went ahead. For others it may not fare that well. Mohammed Kamal is a young man who has been mentally unwell for several years; we will meet him in later chapters. A few months into my fieldwork I discussed with Hajj Khedr, the owner of a local stationery shop, whether he has a chance of getting married one day:

He doesn’t really. If he stays reasonable, calm and settled like he is now for the next five years he may have a chance of marrying, and then not from Mūt, but from the villages, where people might not know his past, or if they do, wouldn’t have seen him in the state people in Mūt have. Even his brother had to marry from outside Mūt. People here worry that problems like this run in the family – the branch extends, and they are wary of marrying their daughters or sons into the family. But there will always be men and women who for some reason or other will settle for a husband or wife with such a history; those who have missed the marriage train or those who don’t have a particularly good reputation.

Behavioural and psychological disturbances constitute such a major blow to a person’s reputation that a disgruntled son allegedly feigned ‘madness’ in order to prevent his father bringing home a step-mother:

I learnt today about a sixty year old man who had lost his wife three years ago and who recently sought marriage in order to have someone take care of him and the house. His youngest son, the only one still living with him, was opposed to this: he didn’t want another woman to replace his mother’s place and have a share in the inheritance. To ruin his father’s chances at marrying he began to behave in aggressive and bizarre ways in town, and to cause trouble. He works in a shop selling chicken and livestock fodder and he began to be rude to customers, refusing to sell to some people without any reason and causing fights when someone objected. He was frequently shouting around town, cursing the people sitting by the coffee-houses, and once took off his shirt and walked half-naked. Some thought he was possessed; the only thing that could explain this sudden change in behaviour. Tariq thought he was doing this intentionally to ruin his father’s chances of getting married. If a family think of marrying their daughter to his father they would now think twice. First they wouldn’t want her to move into a house where a disturbed man lives; this would no doubt cause her problems and grief. Second, they would worry that his father too might be unstable. Even if they think he is possessed and not mentally ill, they would take care and avoid this family. Ever since his father gave up the idea, his son seems to have stopped his disruptive behaviours.

In the quiet squares and streets of Mūt, extreme behavioural and psychological disturbances cannot be missed; they are right there for all to see and hear. A disturbed person can hardly escape being judged by others, but reputation is subject to judgment in the absence of such exotic displays. This is because Mūt is a small place; people know each other and gossip is rife at the coffee-houses, among women in the privacy of their homes, and news travels around at surprisingly fast speeds. This was demonstrated to me one night when I was chatting to some Christian youths who frequent a coffee-house on the outskirts of town. When I returned to El-Midan an hour later I was told by Tariq: “you were sitting with two Christian boys at Sayyed’s coffee-house; see? Your news reaches me”. Perhaps there was a question why, as a Muslim, I was socialising with Christians, a point I will attend to later, but the webs of gossip are most dangerous when someone commits a transgression; the threat to a person’s reputation is at its greatest.

One night while drinking tea with Sayyed and Tariq, the former suggested that we go for a picnic on the dunes just outside town. It was a moon-lit night, and the prospect of leaving town for the cool sand was welcome. Beer and mezza would sustain the night, and Sayyed offered to take the drive-of-shame to the only beer shop in town himself. I started walking with Tariq and mid-way Sayyed picked us up on his motorbike. Drinking alcohol is certainly frowned upon in Dakhla, and we had to keep our wits about us lest someone saw us. Up there on the dunes it was definitely safe. Sayyed was the least concerned about this though; he has a turbulent history of drug use, and has previously told me stories of spectacular drug-fuelled shows in town. But the concern was there nevertheless; Tariq put it this way: “the town is small and talk goes around, if someone sees us here drinking, by the time we return to town the word will be that we had women with us”.

Well into our second beer, we saw a seventies jeep coming fast down the sandy track. We expected it would continue around the dune but it veered left sharply, gained some speed and climbed up the dune adjacent to ours; we heard a woman let out a playful scream. Initially Tariq and Sayyed thought they were foreigners, but then we heard a woman addressing a child “come here!”. My companions’ interest was aroused: they wanted to know who was there and what they were up to. They left me for a brief reconnaissance trip and when they were close enough they saw two children playing in the sand a short distance from the car. The man and woman were not outside and so were obviously in the car. Tariq and Sayyed were convinced the couple were up to some sort of brief sexual liaison, perhaps an engaged couple ‘making out’ and bringing the children with them as an excuse; chaperones who are let loose to play in the sand while they have some private time. This seemed to unsettle my friends; Sayyed was surprised why anyone would “commit dirty acts on this pure sand”. I pointed out that we were drinking alcohol, but he excluded that and said “adultery? I would never do that, everything but penetration, yes, which must be halal (religiously permissible)”.

Perhaps what struck me the most in this incident was my friends’ inconsistency. While they complained of the gossipy nature of their brethren they simultaneously partook in the surveillance of others, and with an intention to expose them if they had known who they were. Several men here have told me with visible pride that they have previously caught couples ‘making out’ in El-Kharaba or other hidden ‘hot-spots’ in Mūt, the same men who have disclosed in confidence that they have previously stolen a kiss or a hug from a girl they once knew. One evening when visiting Hisham at the Dakhla youth-centre I was expected to intervene and ‘catch’ a couple who were kissing in the dark. While waiting for him to finish some errands, I saw a young man walking towards the gate followed shortly by a girl. He was turning periodically and shouting at her “walk, quick!” Half a minute later came the night-guard panting: “catch these two!”

The speed with which news travels around town is guaranteed by the tendency for gossip and the fact that most people know each other, and its efficacy is maintained by the ever present worry of the implications of a tarnished reputation. To me this presented a serious constraint on personal freedom, a view that others did not share. Tariq asked rhetorically: “what would you want to do behind people’s back, sex? If you do this here it will be known, you will know people know without them having to tell you; you will see it in the way they look at you. It’s a good thing that people know each other and news spreads; it keeps the dirtiness at bay”. A quintessential example of such ‘dirtiness’ and the power of the mechanisms to counteract it were demonstrated to me over the course of my stay through the developing story of a Christian boy and a Muslim girl who were caught in the act.

I first heard about them on a visit to Youssef at his office in El-Sha’arawy primary school. We were discussing the details of a lecture on mental health I was about to deliver to school teachers two days later. The school guard came to his office and asked us if we had heard: “an hour ago a young man and a girl were found at the back of a store, they were undressed and the man was taken to the police station”. The following evening I overheard an independent update on the event. The girl wears a niqab (full face veil) as a decoy, her husband had been working in Saudi Arabia for the past three months and the consensus was that she was looking for sex. A month later I learnt that her husband had divorced her and she was forced to leave Mūt and live in one of the villages where people might not know about the scandal. The boy was placed under surveillance, the purpose of which was to protect him: the incident had enraged Muslim men. While this incident demonstrates the serious consequences of sexual transgressions in general, the seriousness of the transgression in this instance was amplified by the fact that the man was Christian and the woman Muslim. What happened was an affront to Islam, and Islam for the people of Dakhla is the global basis of their identity.

[1] This is problematic since, not being a brother or uncle, he remains permissible in marriage.

[2] This refers to the wedding night when bride and groom move to the marital abode and experience their first moment of intimacy.

[3] The literal translation of mot’a is enjoyment or pleasure. A mot’a marriage is a temporary marriage conducted in order to legalise and render permissible the union between a man and a woman primarily to facilitate temporary sexual relations. Nowadays it is rare and is generally frowned upon.

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