Madness & Society: Pathways to Reconciliation

cropped-img_9832.jpg

On the 10th of July 2019 I delivered the Annual Lecture of the Lived Experiences of Distress Research Group at the London South Bank University. The title of the talk was Madness & Society: Pathways to Reconciliation.

Thank you to Professor Paula Reavey for the invitation, and thank you to Seth Hunter for the introduction.

The talk explored three main questions:

  1. What is reconciliation?

  2. What are the challenges to societal reconciliation with Mad activism?

  3. What can be done about these challenges?

Click on the following links for:

Transcript of the talk (pdf)

Audio recording of the event

Slides (PowerPoint)

 

Advertisements

Aimless in Australia

IMG_7905

I was woken up at 6.34 a.m. by the sound of Chinese chatter outside my door. Room 407 was right opposite the lift and in my immediate post-waking stupor, the repeated ding-dongs and the upward and downward inflections of Mandarin amounted to a form of torture. The Great Southern Hotel where I had been staying for the past two nights was in the heart of Sydney’s Central Business District, right on the edge of China Town, and two hundred metres from Central Station, Sydney’s main transport hub. A good location no doubt, yet it was a hotel of whom only one of the adjectives in its self-appointed title was true; there was nothing great about the Great Southern Hotel, or perhaps nothing great anymore. Built in 1858 and extended to seven floors in 1903, it sported an impressive Art Deco façade and a marble laden lobby. It stood incongruously amid the eateries of China Town, surrounded by modern, ugly glass towers. Even though the rooms of the hotel had clearly been renovated recently, the renovations must have been conducted under a limited budget, for why else would the rooms fail to be either functional or beautiful? The carpet was ugly, the water-pressure non-existent, the A.C. had two settings: sweltering hot or freezing cold, the T.V. was untunable, the mattress broke your back, the blanket was covered in hair, and the fridge – whose only contents were two small packets of soured milk – stank. It reminded me of the dodgy bed and breakfasts around Sussex Gardens in Paddington. Back in 2003, during my exile in Hull, I would spend a couple of nights at one of those places on my weekend escapes to London. These were establishments that were not loved by anyone and, accordingly, did not love anyone back. You do not need to believe in Feng Shui to know that a building can repulse you, or be repulsed by you.

Good thing, then, that I was leaving. Yes, that was my last morning at the Great Southern Hotel and in Sydney. And there was no better day to leave than this. Last night, the weather had taken a turn; the sunny and pleasantly warm winter days of the previous week gave way to a daring wind and an increasingly confident rain. As the temperature dropped, my winter coat, once again, came to the forefront of my wardrobe. Yes, it was the perfect time to leave New South Wales and head to Queensland, the state famous for its sunshine, its national parks, its tropical beaches, its great reef, and its not-so-open-minded inhabitants (as the New South Welsh and the Victorians I had met in Sydney were quick to warn me). But it would be a lie if I were to claim that I had any reason to go to Queensland, or any grand plan. In fact, I had no personal reason to come to Australia, and had it not been for the invitation to speak at the seriously titled conference Culture, Cognition, and Mental Illness, it is unlikely I would have set foot on this continent.

I’ve never had a burning urge to go to Australia. It never struck me as a place I ought to visit before I’ve travelled in South America and East Asia to my satisfaction, and I haven’t yet. I have similar sentiments about Canada, a country that is so low on my list of travel priorities it is unlikely I will ever get to it. I’ve often wondered why I harbour these sentiments. To be sure, there is something unattractive about the New World nations owing to their often tarnished histories; perhaps distance has something to do with it, a point that definitely applies to Australia as I was to learn during the brutal experience of 22 hours of confinement in an economy seat; maybe there’s a personal prejudice lurking somewhere, a prejudice regularly stoked by the encounters I have had with a certain type of Australian in London. You could say that my travel consciousness of the world never really included Australia, a consciousness that, during high-school in Egypt in the 90s, was directed towards Europe.

In the late 90s and the first decade of the millennium I had my fill travelling in Europe. The first country I travelled to completely on my own was Germany in 1995, followed by Morocco in 1997, Spain in 1998, Norway in 1999, and California and Nevada in 2000. After moving to England in 2003, I made best use of my new-found proximity to Europe to explore the continent and I made no less than twenty-five visits to many of its countries. From 2006 onwards, my travel consciousness expanded markedly: China, South Africa, Mozambique, Cuba, Chile, Bolivia, Peru, Namibia, Lebanon, Swaziland, Lesotho. Yet, aside from a three week visit to New Zealand in 2012 – also motivated by conference attendance – it never occurred to me to set foot in that part of the world. It’s not strange that my travel consciousness had developed in this way. When Egyptians travel, they invariably go to Europe, and in particular to the Northern and Western parts of Europe. I know very few Egyptians who have ventured beyond this region. It’s where my father cut his travelling teeth, and where I sharpened mine. And perhaps if I had not had the chance to really satisfy my European curiosity, I would not have ventured further either. But something more is going on: Egyptians have a specific idea of what travelling should be about. For many Egyptians, the idea of leaving Cairo to holiday, say, in New Delhi is absurd – why would you replace one maniacal metropolis for another? And so is the idea of going ‘camping’ – a good holiday is defined by comfort, shopping, and a smattering of culture, and not by tents, cold oats, mosquito nets, and bush toilets.

Mohammed Abouelleil Rashed, Syndey 2018

(tbc someday)

Best of 2018 Philosophy List by Oxford University Press

Philosophy-BEST-OF-2017-AKT11460-with-2017-v2-980-x-160

Check out Oxford University Press’ list of articles chosen from across its journals to represent the ‘Best of 2018’.

My article In Defense of Madness: The Problem of Disability is included under the entries for the Journal of Medicine and Philosophy.

For other articles, I enjoyed reading Roger Scruton’s Why Beauty Matters in The Monist.

Madness & the Demand for Recognition

Kan Zaman...

mandess coverAfter four years of (almost) continuous work, I have finally completed my book:

Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism.

You can find the book at the Oxford University Press website and at Amazon.com.A preview with the table of contents, foreword, preface, and introduction is here.

Madness is a complex and contested term. Through time and across cultures it has acquired many formulations: for some, madness is synonymous with unreason and violence, for others with creativity and subversion, elsewhere it is associated with spirits and spirituality. Among the different formulations, there is one in particular that has taken hold so deeply and systematically that it has become the default view in many communities around the world: the idea that madness is a disorder of the mind.

Contemporary developments in mental health activism pose a radical challenge to psychiatric and societal…

View original post 135 more words

Public Mental Health Across Cultural Contexts: An Essay on the Ethics of Primary Prevention of Depression, With a Focus on the Dakhla Oasis of Egypt

(Introduction to a chapter I wrote with Rachel Bingham. It will be part of the volume ‘Mental Health as Public Health: Interdisciplinary Perspectives on the Ethics of Prevention’, edited by Kelso Cratsley and Jennifer Radden.)

 

P1000731

 

For over a decade there has been an active and ambitious movement concerned with reducing the “global burden” of mental disorders in low- and middle-income countries.[1] Global Mental Health, as its proponents call it, aims to close the “treatment gap”, which is defined as the percentage of individuals with serious mental disorders who do not receive any mental health care. According to one estimate, this amounts to 75%, rising in sub-Saharan Africa to 90% (Patel and Prince 2010, p. 1976). In response to this, the movement recommends the “scaling up” of services in these communities in order to develop effective care and treatment for those who are most in need. This recommendation, the movement states, is founded on two things: (1) a wealth of evidence that medications and psychosocial interventions can reduce the disability accrued in virtue of mental disorder, and (2) closing the treatment gap restores the human rights of individuals, as described and recommended in the Convention on the Rights of Persons with Disabilities (Patel et al. 2011; Patel and Saxena 2014).

In addition to its concern with treatment, the movement has identified prevention among the “grand challenges” for mental and neurological disorders. It states, among its key goals, the need to identify the “root causes, risk and protective factors” for mental disorders such as “modifiable social and biological risk factors across the life course”. Using this knowledge, the goal is to “advance prevention and implementation of early interventions” by supporting “community environments that promote physical and mental well-being throughout life” and developing “an evidence-based set of primary prevention interventions” (Collins et al. 2011, p. 29). Similar objectives have been raised several years before by the World Health Organisation, who identified evidence-based prevention of mental disorders as a “public health priority” (WHO 2004, p. 15).

Soon after its inception, the movement of Global Mental Health met sustained and substantial critique.[2] Essentially, critics argue that psychiatry has significant problems in the very contexts where it originated and is not a success story that can be enthusiastically transported to the rest of the world.[3] The conceptual, scientific, and anthropological limitations of psychiatry are well known and critics appeal to them in making their case. Conceptually, psychiatry is unable to define ‘mental disorder’, with ongoing debates on the role of values versus facts in distinguishing disorder from its absence.[4] Scientifically, the lack of discrete biological causes, or biomarkers, for major psychiatric conditions has resulted in the reliance on phenomenological and symptomatic classifications. This has led to difficulties in defining with precision the boundaries between disorders, and accusations that psychiatric categories lack validity.[5] Anthropologically, while the categories themselves are associated with tangible and often severe distress and disability, they remain culturally constructed in that they reflect a ‘Western’ cultural psychology (including conceptions of the person and overall worldview).[6] Given this, critics see Global Mental Health as a top-down imposition of ‘Western’ norms of health and ideas of illness on the ‘Global South’, suppressing long-standing cultural ideas and healing practices that reflect entirely different worldviews. It obscures conditions of extreme poverty that exist throughout many non-Western countries, and which underpin the expressions of distress that Global Mental Health now wants to medicalise. On the whole, Global Mental Health, in the words of the critics, becomes a form of “medical imperialism” (Summerfield 2008, p. 992) that “reproduces (neo)colonial power relationships” (Mills and Davar 2016, p. 443).

We acknowledge the conceptual, scientific, and anthropological critiques of psychiatry and have written about them elsewhere.[7] At the same time we do not wish to speculate about and judge the intention of Global Mental Health, or whether it’s a ‘neo-colonial’ enterprise that serves the interests of pharmaceutical companies. Our concern is to proceed at face-value by examining a particular kind of interaction: on one hand, we have scientifically grounded public mental health prevention campaigns that seek to reduce the incidence of mental disorders in low- and middle-income countries; on the other hand, we have the cultural contexts in these countries where there already are entirely different frameworks for categorising, understanding, treating, and preventing various forms of distress and disability. What sort of ethical principles ought to regulate this interaction, where prevention of ‘mental disorders’ is at stake?

The meaning of prevention with which we are concerned in this chapter is primary, universal prevention, to be distinguished from mental health promotion, from secondary prevention, and from primary prevention that is of a selective or indicated nature. Primary prevention “aims to avert or avoid the incidence of new cases” and is therefore concerned with reducing risk factors for mental disorders (Radden 2018, p. 127, see also WHO 2004, p. 16). Secondary prevention, on the other hand, “occurs once diagnosable disease is present [and] might thus be seen as a form of treatment” (Radden 2018, p. 127). In contrast to prevention, mental health promotion “employs strategies for strengthening protective factors to enhance the social and emotional well-being and quality of life of the general population” (Peterson et al. 2014, p. 3). It is not directly concerned with risk factors for disorders but with positive mental health. With universal prevention the entire population is within view of the interventions, whereas with selective and indicated prevention, the target groups are, respectively, those “whose risk for developing the mental health disorder is significantly higher than average” and those who have “minimal but detectable signs or symptoms” (Evans et al. 2012, p .5). While there is overlap among these various efforts, we focus on primary, universal prevention. Our decision to do so stems from the fact that such interventions, in being wholly anticipatory and population wide put marked, and perhaps even unique, ethical pressure on the encounter between the cultural context (and existing ideas on risk and prevention of distress and disability) and the biomedical public mental health approach.

It is helpful for ethical analysis to begin with a sufficiently detailed understanding of the contexts and interactions that are the subject of analysis. With these details at hand, what matters in a particular interaction is brought to light and the ethical issues become easier to grasp. Accordingly, we begin in section 2 with an ethnographic account of the primary prevention of ‘depression’ in the Dakhla Oasis of Egypt from the perspective of the community. The Dakhla Oasis is a rural community where there is no psychiatric presence or modern biomedical concepts yet – like most communities around the world – there is no shortage of mental-health related distress and disability. It is a paradigmatic example of the kind of community where Global Mental Health would want to action its campaigns. In section 3 we move on to the perspective of a Public Health Team concerned with preventing depression in light of scientific and evidence-based risk factors and preventive strategies. Section 4 outlines the conflict between the perspective of the Team and that of the community. Given this conflict, sections 5 and 6 discuss the ethical issues that arise in the case of two levels of intervention: family and social relationships, and individual interventions.

Notes:

[1] See Horton (2007), Prince et al. (2007), and Saxena et al. (2007).

[2] Most recently there was vocal opposition to a ‘Global Ministerial Mental Health Summit’ that was held on the 9th and 10th of October 2018 in London. The National Survivor and User Network (U.K.) sent an open letter to the organisers of the summit, objecting to the premise, approach, and intention of Global Mental Health.

[3] See Summerfield (2008, 2012, 2013), Mills and Davar (2016), Fernando (2011), and Whitley (2015).

[4] For debates on the definition of the concept of mental disorder consult Boorse (2011), Bolton (2008, 2013), Varga (2015), and Kingma (2013).

[5] For discussions of the (in)validity of psychiatric categories see Kinderman et al. (2013), Horwitz and Wakefield (2007), and Timimi (2014). Often, the problem is framed by asking whether mental disorders are natural kinds (see Jablensky 2016, Kendell and Jablensky 2003, Zachar 2015, and Simon 2011).

[6] See, for example, Fabrega (1989), Littlewood (1990), and Rashed (2013a).

[7] For example: Rashed and Bingham (2014), Rashed (2013b), and Bingham and Banner (2014).

Jennifer Radden: “Rethinking disease in psychiatry: Disease models and the medical imaginary”

Abstract

The first decades of the 21st century have seen increasing dissatisfaction with the diagnostic psychiatry of the American Psychiatric Association’s Diagnostic and Statistical Manuals (DSMs). The aim of the present discussion is to identify one source of these problems within the history of medicine, using melancholy and syphilis as examples. Coinciding with the 19th‐century beginnings of scientific psychiatry, advances that proved transformative and valuable for much of the rest of medicine arguably engendered, and served to entrench, mistaken, and misleading conceptions of psychiatric disorder. Powerful analogical reasoning based on what is assumed, projected, and expected (and thus occupying the realm of the medical imaginary), fostered inappropriate models for psychiatry. Dissatisfaction with DSM systems have given rise to alternative models, exemplified here in (i) network models of disorder calling for revision of ideas about causal explanation, and (ii) the critiques of categorical analyses associated with recently revised domain criteria for research. Such alternatives reflect welcome, if belated, revisions.

Click here for paper