The Identity of Psychiatry and the Challenge of Mad Activism: Rethinking the Clinical Encounter

[Introduction to an essay currently in press with the Journal of Medicine & Philosophy]

Psychiatry has an identity in the sense that it is constituted by certain understandings of what it is and what it is for. The key element in this identity is that psychiatry is a medical speciality. During the early years of their training, medical doctors make a choice about the speciality they want to pursue. Psychiatry is one of them, and so is ophthalmology, cardiology, gynaecology, and paediatrics. Modern medical specialities share some fundamental features: they treat conditions, disorders, or diseases; they aspire to be evidence-based in the care and treatments they offer; they are grounded in basic sciences such as physiology, anatomy, histology, and biochemistry; and they employ technology in investigations, research, and development of treatments. These features characterize modern medical specialities even as physicians are increasingly framing their work in ways that take account of the whole person, recognising conflicting values and their implications for diagnosis and treatment, and acknowledging the role of the arts and humanities in medical education and practice (see, for example, Cox, Campbell, and Fulford 2007; Fulford, van Staden, and Crisp 2013; Cook 2010; and McManus 1995).

Psychiatry differentiates itself from other medical specialties by the conditions that it treats: mental health conditions or disorders, to be contrasted with physical health conditions or disorders. The nature of its subject matter, which are disturbances of the mind and their implications, raises certain complexities for psychiatry that, in extreme, are sometimes taken to suggest that psychiatry’s positioning as a medical speciality is suspect; these include the normative nature of psychiatric judgements, the explanatory limitations of psychiatric theories, and the classificatory inaccuracies that beset the discipline.

There are significant, ongoing debates in these three areas that do not, at present, appear to be nearing resolution. But these debates are themselves superseded by a foundational challenge to psychiatry’s identity as a medical speciality, a challenge that emanates from particular approaches in mental health activism. These approaches, which I will be referring to as Mad activism, reject the language of ‘mental illness’ and ‘mental disorder’, and with it the assumption that people have a condition that requires treatment. The idea that medicine treats conditions, disorders, or diseases is at the heart of medical practice and theory, and this includes psychiatry in so far as it wishes to understand itself as a branch of medicine. In rejecting the premise that people ‘have’ a ‘condition’, Mad activism is issuing a challenge to psychiatry’s identity as a medical speciality.
In this paper I examine how psychiatry might accommodate the challenge of Mad activism in the context of the clinical encounter.

CONTINUE READING HERE

Madness & Society: Pathways to Reconciliation

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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)

 

Best of 2018 Philosophy List by Oxford University Press

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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.

Public Mental Health Across Cultures: The Ethics of Primary Prevention of Depression, Focusing 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.)

 

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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.

PDF

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

 

 

On the idea of Mad Culture (and a comparison with Deaf Culture)

  1. WHAT IS CULTURE?

 Part of the difficulty in making sense of the notion of Mad culture is the meaning of culture as such. The term ‘culture’ refers to a range of related concepts which are not always sufficiently distinguished from each other in various theoretical discussions. There are, at least, three concepts of culture (see Rashed 2013a and 2013b):

  • Culture as an activity: the “tending of natural growth” (Williams 1958, p. xvi); “to inhabit a town or district, to cultivate, tend, or till the land, to keep and breed animals” (Jackson 1996, p. 16); to grow bacteria in a Petri-dish; to cultivate and refine one’s artistic and intellectual capacities – to become cultured. This final meaning – culture as intellectual refinement – lives today in the Culture section of newspapers.
  • Culture as an analytic concept in the social sciences: this is the concept of culture that we find, for example, in the academic discipline of anthropology. The academic concept of culture has evolved rapidly since its introduction by Edward Tylor in the late 19th[1] Today, ‘culture’ is used to refer to socially acquired and shared symbols, meanings, and significances that structure experience, behaviour, interpretation, and social interaction; culture “orients people in their ways of feeling, thinking, and being in the world” (Jenkins and Barrett 2004, p. 5; see Rashed 2013a, p. 4). As an analytic concept it enables researchers and theoreticians to account for the specific nature of, and the differences among, social phenomena and peoples’ subjective reports of their experiences. For example, a prolonged feeling of sadness can be explained by one person as the effect of a neurochemical imbalance, by another as the effect of malevolent spirits, and by another as a test of one’s faith: these differences can be accounted for through the concept of culture. (See Risjord (2012) for an account of various models of culture in the social sciences.)

When we refer to ‘culture’ in constructions such as Mad culture and Maori culture we are not appealing to either of the two concepts of culture just outlined. For what we intend is not an activity or an analytic concept but a thing. This brings us to the third concept of culture I want to outline and the one that features in political discussions on cultural rights.

  • Culture as a noun: this is the societal concept of culture; Will Kymlicka (1995, p. 76) defines it as follows:

a culture which provides its members with meaningful ways of life across the full range of human activities, including social, educational, religious, recreational, and economic life, encompassing both public and private spheres. These cultures tend to be territorially concentrated, and based on a shared language.

Similarly, Margalit and Halbertal (1994, pp. 497-498) understand the societal concept of culture “as a comprehensive way of life”, comprehensive in the sense that it covers crucial aspects of individuals’ lives such as occupations, the nature of relationships, a common language, traditions, history, and so on. Typical examples of societal cultures include Maori, French-Canadian, Ultra-Orthodox Jewish, Nubian, and Aboriginal Canadian cultures. All these groups have previously campaigned for cultural rights within the majorities in which they exist, such as the right to engage in certain practices or to ensure the propagation of their language or to protect their way of life.

To stave off the obvious objections to this final concept of culture I point out that there is no necessary implication here that a given societal culture is fixed in time – Nubian culture can change while remaining ‘Nubian’. Neither is there an implication that all members of the community agree on what is necessary and what is contingent in the definition of their culture, or on the extent of the importance of this belief or that practice. And neither is a societal culture hermetically sealed from the outside world: “there is no watertight boundary around a culture” is the way Mary Midgley (1991, p. 83) puts it. Indeed it is because there is no hermetic seal around a societal culture that it can change, thrive, or disintegrate in light of its contact with other communities. In proceeding, then, I consider the key aspects of a societal culture to be that it is enduring (it existed long before me), shared (there many others who belong to it), and comprehensive (it provides for fundamental aspects of social life). In light of a societal culture’s appearance of independence, it can be looked upon as a ‘thing’ that one can relate to in various ways such as being part of it, alienated from it, rejected by it, or rejecting it. Can Madness constitute a culture in accordance with this concept?

2. CAN MADNESS CONSTITUTE A CULTURE? 

In the activist literature we find descriptions of elements of Mad culture, as the following excerpts indicate:

Is there such a thing as a Mad Culture? … Historically there has been a dependence on identifying Mad people only with psychiatric diagnosis, which assumes that all Mad experiences are about biology as if there wasn’t a whole wide world out there of Mad people with a wide range of experiences, stories, history, meanings, codes and ways of being with each other. Consider some of these basics when thinking about Madness and Mad experiences: We have all kinds of organized groups (political or peer) both provincially and nationally. We have produced tons and tons of stories and first person accounts of our experiences. We have courses about our Mad History. We have all kinds of art which expresses meaning – sometimes about our madness. We have our own special brand of jokes and humour. We have films produced about our experiences and interests. We have rights under law both Nationally and internationally. We have had many many parades and Mad Pride celebrations for decades now. (Costa 2015, p.4 – abridged, italics added)

As the italicised words indicate, this description of Mad culture recalls key aspects of culture: shared experiences, shared histories, codes of interaction and mutual understanding, social organisation, creative productions, cultural events. Many of these notions can be subsumed under the idea that Mad people have unique ways of looking at and experiencing the world:

Mad Culture is a celebration of the creativity of mad people, and pride in our unique way of looking at life, our internal world externalised and shared with others without shame, as a valid way of life. (Sen 2011, p.5)

When we talk about cultures, we are talking about Mad people as a people and equity-seeking group, not as an illness… As Mad people, we have unique ways of experiencing the world, making meaning, knowing and learning, developing communities, and creating cultures. These cultures are showcased and celebrated during Mad Pride (Mad Pride Hamilton).

A key component of culture is a shared language, and cultural communities are frequently identified as linguistic communities (e.g. the French-Canadians or the Inuit). A similar emphasis on language and shared understanding can also be found in accounts of Mad culture:

As Mad people we develop unique cultural practices: We use language in particular ways to identify ourselves (including the reclamation of words like crazy, mad, and nuts). We form new understandings of our experiences that differ from those of biomedical psychiatry. (deBei 2013, p. 8)

The experience of Madness produces unique behaviour and language that many Normals don’t understand but which make complete sense to many of us. (Costa 2015, p.4)

We can find a community in our shared experiences. We can find a culture in our shared creativity, our comedy and compassion. Sit in a room full of Nutters and one Normal, see how quickly the Normal is either controlling the conversation or outside of it. They do not share our understanding of the world, and here you can see evidence of our Culture, our Community. (Clare 2011, p. 16)

So, can madness constitute a culture? In the foregoing excerpts, activists certainly want to affirm this possibility. But the idea of Mad culture does not fit neatly with communities typically considered to be cultural communities. A typical cultural community, as outlined in section 1, tends to have shared language and practices, a geographic location or locations, a commitment to shared historical narrative(s), and offers for its members a comprehensive way of life. Compared to this, Mad culture appears quite atypical; for example, there is no shared language as such – references to ‘language’ in the previous quotes indicate the kind of private codes that tend to develop between friends who have known each other for many years, and not to a systematic medium of communication. People who identify as Mad, or who are diagnosed with ‘schizophrenia’ or ‘bipolar disorder’, come from all over the world and have no geographic location, no single language or a single shared history (the history of mental health activism in the English speaking world is bound to be different to that in South America). Further, Mad culture does not offer a comprehensive way of life in the same way that Aboriginal Canadian culture may. Mad people can and do form communities of course – Mad Pride and similar associations are a case in point – the question here, however, is whether these can be considered cultural communities.

Perhaps Quebeckers and Maoris are not suitable comparisons to Mad culture. Another community to examine, and which may be more analogous in so far as it also continues to fight medicalisation and disqualification, is Deaf culture. On visiting Gallaudet University in 1986 – a university for the education of deaf students – Oliver Sacks (1989, p. 127) remarked upon “an astonishing and moving experience”:

 I had never before seen an entire community of the deaf, nor had I quite realized (even though I knew this theoretically) that Sign might indeed be a complete language – a language equally suitable for making love or speeches, for flirtation or mathematics. I had to see philosophy and chemistry classes in Sign; I had to see the absolutely silent mathematics department at work; to see deaf bards, Sign poetry, on the campus, and the range and depth of the Gallaudet theatre; I had to see the wonderful social scene in the student bar, with hands flying in all directions as a hundred separate conversations proceeded – I had to see all this for myself before I could be moved from my previous “medical” view of deafness (as a “condition,” a deficit, that had to be treated) to a “cultural” view of the deaf as forming a community with a complete language and culture of its own.

In Sacks’ account, Sign language appears as a central component of Deaf culture – the core from which other cultural practices and attitudes arise. The centrality of Sign to the Deaf community is confirmed through a perusal of writings on Deaf culture: the World Federation of the Deaf describes Deaf people as “a linguistic minority” who have “a common experience of life” manifesting in “Deaf culture”.[2] Acceptance of a deaf person into the Deaf community, they continue, “is strongly linked to competence in a signed language”. In Inside Deaf Culture, Padden and Humphries (2005, p. 1) note that even though the Deaf community does not possess typical markers of culture – religion, geographical space, clothing, diet – they do possess sign language(s), which play a “central role … in the everyday lives of the community”. The British Deaf Association remarks upon Deaf people as a linguistic minority who have a “unique culture” evident in their history, tradition of visual story-telling, and the “flourishing of BSL in a range of art forms including drama, poetry, comedy and satire”.[3] Similarly, the Canadian Cultural Society of the Deaf and the American non-profit organisation Hands & Voices both describe Sign language as the core of Deaf cultural communities.[4] Sign language is central to Deaf culture and is the crux around which a sense of community can arise. This community fosters awareness of being Deaf as a positive and not a deficit state; the deaf person is frequently described as the Seeing person (distinct from the Hearing person), emphasising the visual nature of Sign language and Deaf communication.[5] Deaf culture is also supported by the existence of institutions dedicated for Deaf people such as schools, clubs, and churches. Finally, as a consequence of living in a world not always designed for them, and in the process of campaigning for their rights and the protection of their culture, Deaf people develop a sense of community and solidarity.

Even though Deaf culture differs from typical cultural communities, in its most developed form it does approach the ideal of offering its members “meaningful ways of life” across key human activities (Kymlicka 1995, p. 76). It may not be a comprehensive culture in the way that Ultra-Orthodox Jewish culture is, but its central importance to the life of some deaf people – arising in particular from learning and expressing oneself in Sign – suggests that it can be viewed as a cultural community.

If we compare Mad culture to Deaf culture we find many points of similarity. For example, like Deaf people, people who identify as Mad – at least in the English-speaking world – are united by a set of connected historical narratives, by opposition to ‘sanism’ and psychiatric coercion, and by phenomenologically related experiences (such as voices, unusual beliefs, and extremes of mood).[6] In addition, they share a tradition of producing distinctive art and literature and a concern with transforming negative perceptions in society surrounding mental health. But Mad people, unlike Deaf people, are not a linguistic community, and this does weaken the coherence of the idea that madness can constitute a culture. An alternative is to regard Mad people as forming associations within the broader cultural context in which they live, the very context they are trying to transform in such a way that allows them a better chance to thrive.

The comparisons drawn in this section cannot be the final word, as it is conceivable for different conceptions of societal culture and Mad culture to yield different conclusions. However, in what follows I shall argue that even if madness can constitute a culture, a consideration of the general justification for cultural rights leads us to social identity and not directly to culture as the key issue at stake.

 

Mohammed Abouelleil Rashed (2018)

Note: the above is an excerpt from Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism (Oxford University Press, 2019).

***

[1] In Primitive Culture, Edward Tylor (1891, p. 1) provided the following definition: “culture or civilisation .. is that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of a society”.

[2] Online: https://wfdeaf.org/our-work/focus-areas/deaf-culture

[3] British Sign Language. Online: https://www.bda.org.uk/what-is-deaf-culture

[4] Online: http://www.deafculturecentre.ca/Public/Default.aspx?I=294. http://www.handsandvoices.org/comcon/articles/deafculture.htm

[5] Online: http://www.handsandvoices.org/comcon/articles/deafculture.htm

[6] Sanism: discrimination and prejudice against people perceived to have, or labelled as having, a mental disorder. The equivalent term in disability activism is ableism.

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Religious Fundamentalism, Scientific Rationality, and the Evaluation of Social Identities

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[Excerpt from Chapter 10 of Madness and the Demand for Recognition (2019, OUP)]

Referring to religious fundamentalism, Gellner (1992, p. 2) writes:

The underlying idea is that a given faith is to be upheld firmly in its full and literal form, free of compromise, softening, re-interpretation or diminution. It presupposes that the core of religion is doctrine, rather than ritual, and also that this doctrine can be fixed with precision and finality.

Religious doctrine includes fundamental ideas about our nature, the nature of the world and the cosmos, and the manner in which we should live and treat each other. In following to the letter the doctrines of one’s faith, believers are trying to get it right, where getting it right means knowing with exactness what God intended for us. In the case of Islam, the tradition I know most about, the Divine intent can be discerned from the Qur’an (considered to be the word of the God) and the Traditions (the sayings) attributed to the Prophet (see Rashed 2015b).[1] The process of getting it right, therefore, becomes an interpretive one, raising questions such as: how do we understand this verse; what does God mean by the words ‘dust’ and ‘clot’ in describing human creation; who did the Prophet intend by this Tradition; does this Tradition follow a trusted lineage of re-tellers?

We can see that ‘getting it right’ for the religious fundamentalist and for the scientific rationalist mean different things – interpreting the Divine intent, and producing true explanations of the nature of the world, respectively. But then we have a problem, for religious doctrine often involves claims whose truth – in the sense of their relation to reality – can, in principle, be established. Yet in being an interpretive enterprise, religious fundamentalism cannot claim access to the truth in this sense. The religious fundamentalist can immediately respond by pointing out that the Divine word corresponds to the truth; it is the truth. If we press the religious fundamentalist to tell us why this is so we might be told that the truth of God’s pronouncements in the Qur’an is guaranteed by God’s pronouncement (also in the Qur’an) that His word is the truth and will be protected for all time from distortion.[2] Such a circular argument, of course, is unsatisfactory, and simply points to the fact that matters of evidence and logic have been reduced to matters of faith. If we press the religious fundamentalist further we might encounter what has become a common response: the attempt to justify the truth of the word of God by demonstrating that the Qur’an had anticipated modern scientific findings, and had done so over 1400 years ago. This is known as the ‘scientific miracle of the Qur’an’; scholars interpret certain ambiguous, almost poetic verses to suggest discoveries such as the relativity of time, the process of conception, brain functions, the composition of the Sun, and many others. The irony in such an attempt is that it elevates scientific truths to the status of arbiter of the truth of the word of God. But the more serious problem is that science is a self-correcting progressive enterprise – what we know today to be true may turn out tomorrow to be false. The Qur’an, on the other hand, is fixed; every scientific claim in the Qur’an (assuming there are any that point to current scientific discoveries) is going to be refuted the moment our science develops. You cannot use a continually changing body of knowledge to validate the eternally fixed word of God.

Neither the faith-based response nor the ‘scientific miracle of the Qur’an’ response can tie the Divine word to the truth. From the stance of scientific rationality, all the religious fundamentalist can do is provide interpretations of the ‘Divine’ intent as the latter can be discerned in the writings of his or her tradition. Given this, when we are presented with identities constituted by doctrinal claims whose truth can, in principle, be established (and which therefore stand or fall subject to an investigation of their veracity), we cannot extend a positive response to these identities; scientific rationality is within its means to pass judgement.

But not all religion is purely doctrinal in this sense or, more precisely, its doctrines are not intended as strictly factual claims about the world; Appiah (2005, p. 188) makes this point:

Gore Vidal likes to talk about ancient mystery sects whose rites have passed down so many generations that their priests utter incantations in language they no longer understand. The observation is satirical, but there’s a good point buried here. Where religious observance involves the affirmation of creeds, what may ultimately matter isn’t the epistemic content of the sentences (“I believe in One God, the Father Almighty …”) but the practice of uttering them. By Protestant habit, we’re inclined to describe the devout as believers, rather than practitioners; yet the emphasis is likely misplaced.

This is a reasonable point; for many people, religion is a practical affair: they attend the mosque for Friday prayers with their family members, they recite verses from the Qur’an and repeat invocations behind the Imam, and they socialise with their friends after the prayer, and during all of this, ‘doctrine’ is the last thing on their minds. They might even get overwhelmed with spiritual feelings of connectedness to the Divine. In the course of their ritual performance, they are likely to recite verses the content of which involves far-fetched claims about the world. It would be misguided to press them on the truth of those claims (in an empirical or logical sense), as it would be to approach, to use Taylor’s (1994a, p. 67) example, “a raga with the presumptions of value implicit in the well-tempered clavier”; in both cases we would be applying the wrong measure of judgement, it would be “to forever miss the point” (ibid.).[3]

And then there is the possibility that the ‘truths’ in question are metaphorical truths, symbolic expressions of human experience, its range and its moral heights and depths. Charles Taylor (2007, 1982) often talks about the expressive dimension of our experience, a dimension that has been largely expunged from scientific research and its technological application. Human civilizations have always developed rich languages of expression, religious languages being a prominent example. The rarefied language of scientific rationality and its attendant procedural asceticism are our best bet to get things right about the world, but they are often inadequate as a means to express our psychological, emotional, and moral complexity.

To judge the practical (ritualistic) and expressive dimensions of identities in light of the standards of scientific rationality is to trespass upon these identities. Our judgements are misplaced and have limited value. My contention is that every time we suspect that we do not possess the right kind of language to understand other identities, or that there is an experience or mode of engagement that over-determines the language in which people express their identities, we have a genuine problem of shared understanding; we are not within our means to pass judgements of irrationality on the narratives that constitute these identities. Now I am not suggesting that the distinctions between doctrine and practice, or between understanding the world and expressing ourselves, are easy to make. And neither am I suggesting that a particular case falls neatly on side or the other of these distinctions. But if we are going to adopt the stance of scientific rationality – given that we have to adopt some stance as I have argued earlier – then these are the issues we need to think about: (1) Is the narrative best apprehended in its factual or expressive dimension? (2) Are there experiences that over-determine the kind of narrative that can adequately express them?

In Defense of Madness: The Problem of Disability

By developing a perspective on the social model of disability and by appealing to the concept of intelligiblity, I respond to arguments against Mad Pride activism. You can access the articlm_covere HERE.

The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 44, Issue 2, April 2019, Pages 150–174, https://doi.org/10.1093/jmp/jhy016

 

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 judgments, and the second arises 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.

 

Mohammed Abouelleil Rashed, In Defense of Madness: The Problem of Disability, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 44, Issue 2, April 2019, Pages 150–174, https://doi.org/10.1093/jmp/jhy016

Mad Activism and Mental Health Practice

On the 6th of August 2018 I delivered a live webinar that was part of a Mad Studies series organised by Mad in America. The aim of the webinar was to explore ways of incroporating ideas from Mad activism into clinical practice. The full recording of the webinar and the accompanying slides can be found below.

 

More Things in Heaven and Earth

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For a few months in 2009 and 2010 I was a resident of Mut, a small town in the Dakhla Oasis in the Western desert of Egypt. My aim was to become acquainted with the social institution of spirit possession, and with sorcery and Qur’anic healing (while keeping an eye on how all of this intersects with ‘mental disorder’ and ‘madness’). I learnt many things, among which was the normalness with which spirit possession was apprehended in the community: people invoked spirits to explain a slight misfortune as much as a life- changing event; to make sense of what we would refer to as ‘schizophrenia’, and to make sense of a passing dysphoria. It was part of everyday life. The way in which spirit possession cut across these diverse areas of life got me thinking about the broader role it plays in preserving meaning when things go wrong. To help me think these issues through I brought in the concepts of ‘intentionality’ and ‘personhood’. The result is my essay More Things in Heaven and Earth: Spirit Possession, Mental Disorder, and Intentionality (2018, open access at the Journal of Medical Humanities).

The essay is a philosophical exploration of a range of concepts and how they relate to each other. It appeals sparingly, though decisively, to the ethnography that I had conducted at Dakhla. If you want to know more about the place and the community you can check these blog-posts:

The Dakhla Diaries (1) : Fast to Charing-X, Slow to Hell

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

The Dakhla Diaries (3): Wedding Invitation

Old Mut, Dakhla

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

And this is a piece I published in the newspaper Al-Ahram Weekly (2009) voicing my view on some of the practices that I had observed: To Untie or Knot

 

On Irrational Identities

(Excerpt from Chapter 10 of Madness and the Demand for Recognition. OUP, 2018)

In Chapter 7 I raised and examined the distinction between failed and controversial identities. I began by pointing out that every demand for recognition – all gaps in social validation – involves the perception by each side that the other is committing a mistake. Given this, I formulated the question we had to address as follows: how do we sort out those mistakes that can be addressed within the scope of recognition (controversial identities) from those that cannot (failed identities)? The implication was that a failed identity involves a mistake that cannot be corrected by revising the category with which a person identifies, while a controversial identity involves a mistake that can, in principle, be corrected in that way. The issue I am concerned with here is no longer the identity-claim as such but the validity of the collective category itself; the question is no longer ‘what kind of mistake is the person identifying as x implicated in?’ but ‘is x a valid category?’. This question features as an element of adjudication for the reason that some social identities can be irrational in such a way that they cannot be regarded as meriting a positive social or a political response. As Appiah (2005, p. 181) writes:

Insofar as identities can be characterised as having both normative and factual aspects, both can offend against reason: an identity’s basic norms might be in conflict with one another; its constitutive factual claims might be in conflict with the truth.

For example, consider members of the Flat Earth Society if they were to identify as Flat-Earthers and demand recognition of the validity of their identity. They may successfully demonstrate that society’s refusal to recognise them as successful agents incurs on them a range of social harms such as disqualification. Yet it is clear that their identity does not merit further consideration and this for the reason that it is false: Earth is not flat. A similar predicament befalls some Creationists; Young-Earth Creationists, for example, believe that Earth is about ten thousand years old and was created over a period of six days, a belief that stands against all scientific evidence. It is not unreasonable to suggest that neither the Flat-Earthers nor the Young-Earth Creationists ought to have their identity-claims taken seriously, as the facts that constitute their identities do not measure up to what we know to be true, given the best evidence we now possess. To put it bluntly, whatever else might be at stake between us and the Flat-Earthers or Young-Earth Creationists, the shape of the Earth, its age, and the emergence and development of life on it are not.

Who does ‘us’ refer to in this context? To those who regard scientific rationality as an important value to uphold in society. By scientific rationality I mean an epistemological and methodological framework that prioritises procedural principles of knowledge acquisition (such as empirical observation, atomisation of evidence, and non-metaphysical, non-dogmatic reasoning), and eschews substantive convictions about the world derived from a sacred, divine, or otherwise infallible, authority (see Gellner 1992, p. 80-84). In rejecting the demands of Flat-Earthers and Young-Earth Creationists, we are prioritising the value of scientific rationality over the value of an individual’s attachment to a particular identity. We are saying: we know that it matters to you that your view of the world is accepted by us, but to accept it is to undermine what we consider, in this instance, to be a more important value. Note that such a response preserves the value of free-speech – Flat-Earthers and Young-Earth Creationists are free to espouse their views. Note also that refusing to accord these identities a positive response is a separate issue from taking an active stand against them (an example of the latter would be government intervention to ban the teaching of creationism in schools).[1] What we are trying to determine here is not who should receive a negative response but who is a legitimate candidate for a positive one. Owing to the irrationality of their constituting claims, Flat-Earthers and Young-Earth Creationists are not.

At this point in the argument someone could object to the premise of assessing the rationality of identities. They could object on two grounds: they could say there is no stance from where we can make such assessments; or they could say that even if such a stance exists and it is possible to determine the rationality of an identity, such a determination is always trumped by the demand for recognition and by individuals’ attachment to their identities. Both positions could further argue that as long as an identity is neither trivial nor morally objectionable, it ought to be considered for a positive response. We can recognise in the first position a commitment to cognitive relativism; in the second position we can recognise an extreme form of liberal tolerance. Both positions are problematic…

[1] For an example of what an active stance would look like in such cases and the problems it raises, see Appiah (2005, pp. 182-189) for an ingenious thought experiment based in the mythical Republic of Cartesia. The regime in Cartesia encourages the creed of hard rationalism and actively seeks to transform any deviations from rationality among its citizens.

The Identity of Psychiatry in the Aftermath of Mad Activism

[Introduction to an essay I am working on for a special issue of the Journal of Medicine & Philosophy with the title ‘The Crisis in Psychiatric Science’]

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THE IDENTITY OF PSYCHIATRY IN THE AFTERMATH OF MAD ACTIVISM

  1. INTRODUCTION

 Psychiatry has an identity in the sense that it is constituted by certain understandings of what it is and what it is for. The key element in this identity, and the element from where other features arise, is that psychiatry is a medical speciality. Upon completion of their medical education and during the early years of their training, medical students – now budding doctors – make a choice about the speciality they want to pursue. Psychiatry is one of them, and so is ophthalmology, cardiology, gynaecology, and paediatrics. Modern medical specialities share some fundamental features: they treat conditions, disorders, or diseases; they aspire to be evidence-based in the care and treatments they offer; they are grounded in basic sciences such as physiology, anatomy, histology, and biochemistry; and they employ technology in investigations, research, and development of treatments. All of this ought to occur (and in the best of cases does occur) in a holistic manner, taking account of the whole person and not just of an isolated organ or a system; i.e. person-centred medicine (e.g. Cox, Campbell, and Fulford 2007). In addition, it is increasingly recognised that the arts and humanities have a role to play in medical education, training, and practice. Literature, theatre, film, history, and the various arts, it is argued, can help develop the capacity for good judgement, and can broaden the ability of clinicians to understand and empathise with patients (e.g. Cook 2010, McManus 1995). None of the above, I will assume in this essay, is particularly controversial.

Even though psychiatry is a medical speciality, it is a special medical speciality. This arises from its subject matter, ordinarily conceived of as mental health conditions or disorders, to be contrasted with physical health conditions or disorders. Psychiatry deals with the mind not working as it should while ophthalmology, for example, deals with the ophthalmic system not working as it should. The nature of its subject matter raises certain complexities for psychiatry that, in extreme, are sometimes taken to suggest that psychiatry’s positioning as a medical speciality is suspect; these include the normative nature of psychiatric judgements, the explanatory limitations of psychiatric theories, and the classificatory inaccuracies that beset the discipline.[1] Another challenge to psychiatry’s identity as a medical speciality comes from particular approaches in mental health activism. Mad Pride and mad-positive activism (henceforth Mad activism) rejects the language of ‘mental illness’ and ‘mental disorder’, and rejects the assumption that people have a ‘condition’ that is the subject of treatment. The idea that medicine treats ‘things’ that people ‘have’ is fundamental to medical practice and theory and hence is fundamental to psychiatry in so far as it wishes to continue understanding itself as a branch of medicine. Mad activism, therefore, challenges psychiatry’s identity as a medical speciality.

In this essay, I argue that among these four challenges, only the fourth requires of psychiatry to rethink its identity. By contrast, as I demonstrate in section 2, neither the normative, nor the explanatory, or the classificatory complexities undermine psychiatry’s identity as a medical speciality. This is primarily for the reason that the aforementioned complexities obtain in medicine as a whole, and are not unique to psychiatry even if they are more common and intractable. On the other hand, the challenge of Mad activism is a serious problem. In order to understand what the challenge amounts to, I develop in section 3 the notion of the hypostatic abstraction, a logical and semantic operation which I consider to lie at the heart of medical practice and theory. It distinguishes medicine from other social institutions concerned with human suffering such as religious and some therapeutic institutions. In section 4 I demonstrate how Mad activism challenges the hypostatic abstraction. And in section 5 I discuss a range of ways in which psychiatry can respond to this challenge, and the modifications to its identity that may be necessary.

[1] These are not the only complexities; there are, for example, well-known difficulties and controversies surrounding the efficacy and risks of anti-depressant and anti-psychotic medication. In addition, psychiatry faces distinctive ethical complexities arising from the fact that mental health patients can be particularly vulnerable which raises questions of capacity not ordinarily raised in other medical specialities (see Radden and Sadler 2010).

 

Madness & the Demand for Recognition

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After 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 understandings of madness. Mad Pride and mad-positive activism reject the language of mental ‘illness’ and ‘disorder’, reclaim the term ‘mad’, and reverse its negative connotations. Activists seek cultural change in the way madness is viewed, and demand recognition of madness as grounds for identity. But can madness constitute such grounds? Is it possible to reconcile delusions, passivity phenomena, and the discontinuity of self often seen in mental health conditions with the requirements for identity formation presupposed by the theory of recognition? How should society respond?

Guided by these questions, this book is the first comprehensive philosophical examination of the claims and demands of Mad activism. Locating itself in the philosophy of psychiatry, Mad studies, and activist literatures, the book develops a rich theoretical framework for understanding, justifying, and responding to Mad activism’s demand for recognition.

 

The Motivation for Recognition & the Problem of Ideology

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[Excerpt from Chapter 4 of my book Madness & the Demand for Recognition, forthcoming Oxford University Press, 2018]

 

In the foregoing account of identity (section 4.2) there is frequent mention of the demand for recognition (indeed, the title of the book features the same). We have made some progress towards understanding the nature of the gaps in social validation under which such a demand can become possible: individuals who are unable to find their self-understanding reflected in the social categories with which they identify and who are demanding social change to address this; what motivates people to seek this kind of social change – what motivates them to struggle for recognition?

4.3 THE STRUGGLE FOR RECOGNITION

4.3.1 The motivation for recognition

There are, at least, four possible sources of motivation for recognition. One of these sources has already been identified in the discussion of Hegel’s teleology (section 3.5.1). In accordance with this, the struggle for more equal and mutual forms of recognitive relations is driven forward by the telos of human nature which is the actualisation of freedom: if that is the ultimate goal, then the dialectical development of consciousness’ understanding of itself will lead to an awareness of mutual dependency as a condition of freedom. But this account has been considered and rejected on the grounds that positing an ultimate, rational telos for human beings that tends towards realisation is a problematic assumption, with connotations to the kind of metaphysical theorising which Kant’s critical philosophy had put to rest. The metaphysical source of the motivation for recognition must be rejected.

Another possible source is empirical and has to do with the psychological nature of human beings. In the Struggle for Recognition, Axel Honneth (1996) provides such an account through the empirical social psychology of G. H. Mead. According to Mead (1967) the self develops out of the interaction of two perspectives: the ‘me’ which is the internalised perspective of the social norms of the generalised other, and the ‘I’ which is a response to the ‘me’ and the source of individual creativity and rebellion against social norms. It is the movement of the ‘I’ – the impulse to individuation – that shows up the limitations of social norms and motivates the expansion of relations of recognition (see Honneth 1996, pp. 75-85).

In a later work Honneth (2002, p. 502) rejects his earlier account; he begins by noting: “there has always seemed to me to be something particularly attractive about the idea of an ongoing struggle for recognition, though I did not quite see how it could still be justified today without the idealistic presupposition of a forward-driven process of Spirit’s complete realization”. Honneth thus rejects the teleological account that we, also, found wanting. He then goes on to render problematic his earlier proposal that seeks to ground the motivation for recognition in Mead’s social psychology:

I have come to doubt whether [Mead’s] views can actually be understood as contributions to a theory of recognition: in essence, what Mead calls ‘recognition’ reduces to the act of reciprocal perspective taking, without the character of the other’s action being of any crucial significance; the psychological mechanism by which shared meanings and norms emerge seems to Mead generally to develop independently of the reactive behaviour of the two participants, so that it also becomes impossible to distinguish actions according to their respective normative character. (Honneth 2002, p. 502)

In other words, what Mead describes is a general process that is always occurring behind people’s backs in so far as it is a basic feature of the human life form. His theory explains how shared norms emerge and why they expand but deprives agents’ behaviours towards each other of normative significance. They become unwitting subjects of this process rather than agents struggling for recognition. To struggle for recognition is to perceive oneself to be denied a status one is worthy of, and not to mechanically act out one’s innate nature. And this remains the case even if our treatment by others engenders feelings of humiliation and disrespect. To experience humiliation is to already consider oneself deserving of a certain kind of treatment, of a normative status that is denied. Such feelings, therefore, cannot themselves constitute the motivation for recognition, rather they are symptoms of the prior existence of a conviction that one must be treated in a better way.

If the motivation for recognition cannot be accounted for metaphysically (by the teleology of social existence), or empirically (by the facts of one’s psychological nature), or emotionally (by the powerful feelings that signal the need for social change), then it must somehow be explained with reference to the ideas that together make up the theory of recognition. These ideas include specific understandings of individuality, self-realisation, freedom, authenticity, social dependence, the need for social confirmation, in addition to notions of dignity, esteem, and distinction, among others. To be motivated to struggle for recognition is to already be shaped by a historical tradition where such notions have become part of how we relate to ourselves and others, and the normative expectations that structure such relations; as McBride (2013, p. 137) writes, “we are the inheritors of a long and complex history of ethical, religious, philosophical, and, more recently, social scientific thought about the stuff of recognition: pride, honour, dignity, respect, status, distinction, prestige”. It is partly that we are within the space of these notions that we can see, as pointed out in section 3.5.2, that living a life of delusion and disregard for what others think, or a life of total absorption in social norms, is not to live a worthwhile life, for we would be giving up altogether either on social confirmation or on our individuality. We are motivated by these notions in so far as we are already constituted socially so as to be moved by them.

Putting the issue this way may raise concerns. By grounding the motivation for recognition in the subject’s prior socialisation, it becomes harder to establish whether that motivation is, ultimately, a means for the individual to broaden his or her social freedom, or a means for reproducing existing relations of domination. As McNay (2008, p. 10) writes, “the desire for recognition might be far from a spontaneous and innate phenomenon but the effect of a certain ideological manipulation of individuals” (see also McBride 2013, pp. 37-40; Markell 2003). Honneth (2012, p. 77) provides a number of examples where recognition may be seen as contributing to the domination of individuals:

The pride that ‘Uncle Tom’ feels as a reaction to the constant praises of his submissive virtues makes him into a compliant servant in a slave-owning society. The emotional appeals to the ‘good’ mother and housewife made by churches, parliaments or the mass media over the centuries caused women to remain trapped within a self-image that most effectively accommodated gender-specific division of labour.

Instead of constituting moral progress (in the sense of an expansion of individual freedom), recognition becomes a mechanism by which people endorse the very identities that limit their freedom. They seek recognition for these identities and in this way “voluntarily take on tasks or duties that serve society” (Honneth 2012, p. 75). There is a need, therefore, to see if we can distinguish ideological forms of recognition from those relations of recognition in which genuine moral progress can be said to have occurred, since what we are after are relations of the latter sort.

4.3.2 The problem of ideology

I first consider, and exclude, some ways in which the problem of ideology cannot be solved. It may seem attractive to find a solution by appeal to a Kantian notion of rational autonomy, where the subject withdraws from social life in order to know what it ought to do. If such withdrawal were possible, we would have had an instance of genuine recognition in the sense that an autonomous choice has been made. But as argued in section 3.2, withdrawing to pure reason can only produce the form that moral principles must take, without those principles thereby possessing sufficient content that can guide action. Moral principles acquire content, and hence can be action guiding, through the very social practices that Kant urged us to withdraw from in order to exercise our rational autonomy. Somehow then, the distinction between ideological and genuine recognition, if it can be made at all, will have to be drawn from within those social practices, as an appeal to a noumenal realm of freedom where we can rationally will what we ought to do cannot work. This is further complicated by the fact that both genuine and ideological recognition – being forms of recognition – must meet the approval of the subject in the sense that both must make the subject feel valued and are considered positive developments conducive to individual growth. Hence, the experience of the subject cannot help us here either. Ideological recognition then consists in practices that are “intrinsically positive and affirmative” yet “bear the negative features of an act of willing subjection, even though these practices appear prima facie to lack all such discriminatory features” (Honneth 2012, p. 78). How can these acts of recognition be identified?

The key seems to lie in the notion of ‘willing subjection’ and the possibility of identifying this despite subjects’ pronouncements of their wellbeing. The judgement that particular practices of recognition are ideological in the sense that they constitute acts of willing subjection must therefore be made by an external observer. The observer needs to perceive subjection, while at the same time explaining away the person’s acceptance of the situation as an indication that he has internalised his oppression in such a way that he willing subjects himself. The case of the ‘good mother’ is a case in point; by voluntarily endorsing that role, she remains uncompensated for her work and many other opportunities in life would be foreclosed to her. Now the observer, in this kind of theoretical narrative, is no longer concerned with the quality of interpersonal relations or the subject’s experience of freedom and wellbeing. What is at issue here seems to be that the observer disagrees with the values and beliefs that structure those relations, rather than the quality of those relations being relations of mutual recognition. A contemporary example can further clarify.

Consider the claim, often heard in certain public discourse, that Muslim women who cover their hair – who wear a hijab – are ‘oppressed’. Frequently, the claims made do not require that the women in question report any oppression, and hence concepts such as ‘internalised oppression’ are invoked to explain the lack of a negative experience. Of course, some women are coerced into wearing the hijab, and given the right context they would remove it and see it as an unnecessary imposition on them. For others the hijab is about modesty and has religious connotations. In this sense, it is not a symbol of their oppression and may even be regarded as a feature that can generate positive recognition as a pious and religiously observant person. An observer who claims that the desire for recognition in such cases is ideological – that women who cover their hair are willingly (and subconsciously) subjecting themselves to existing norms – is making a statement about his or her views on the cultural context: the problem the observer has is with the religious weight placed on clothing, or the fact that it is mainly women who have to observe such practices. Some women who wear a hijab reject this account since it bypasses their own understanding of what they are doing and the value they attach to it (in fact such an account can itself end up being a form of misrecognition). Not surprisingly, the exact claim is made in reverse by some Muslim women who argue that ‘Westernised’ women who dress ‘immodestly’ are oppressed by a dominant, male culture that subtly forces them to show their bodies. Those who believe that dressing in this way is an expression of freedom and secularism have simply internalised the values by which they willing subject themselves to existing norms.

The point of presenting this case from both sides is to show that once we bypass people’s accounts of what they are doing, and put aside their reported experience of freedom and wellbeing, we can see that what is going on is an ideological conflict between two worldviews. This conflict can itself be described within the framework of misrecognition as a continued devaluing of agent’s identities under the cover of an interest in their wellbeing. Of course, people are not always right about what they are doing, and our psychological depth is such that we can deceive ourselves and accept an abusive situation, even more not be able to see that it is abusive. We may convince ourselves that a particular role is exactly right for us, whereas others can see that it is obviously limiting our lives. But psychological depth and the possibility of self-deception go both ways; if that person over there is not transparent to himself then neither am I, even if transparency admits of degrees. Hence, if we are going to argue that a person is willingly subjecting herself, we also need to account for our motivations in making such an argument and what we are, in a sense, getting out of it in terms of validating our worldview, our take on what matters.

This perspective on the idea of ‘willing subjection’ should not be interpreted as a call for inaction; what it is, is a call for personalising and contextualising our moral and political responses and analyses of the lives of others. This means that if we are inclined to persuade individuals to change their understanding of their situation, then we cannot simply bypass their experience of wellbeing and their specific circumstances. In other words, sweeping judgements that take the form ‘group x is oppressed’ are not helpful; clearly there are all sorts of possibilities and the only way to sort these out is to be aware of this complexity, without losing sight of ‘structural’ discrimination in a particular community. With this in mind we will find that the spectrum of oppression includes the following: some in group x are oppressed and are already fighting to change that; some do not consider themselves oppressed but change their take on the situation once they are presented with a different analysis of it; some do not consider themselves oppressed – despite clear evidence to the contrary – yet no amount of persuasion can get them to see this; some consider your interest in their freedom as an attempt to oppress them; others consider themselves perfectly free and empowered.

Returning to our original question – the distinction between ideological and genuine forms of recognition – it appeared, to begin with, that the idea of ‘willing subjection’ held the key to that distinction. However, on having a closer look at this idea it emerged that what it communicates is a conflict of worldviews rather than a view on the quality of interpersonal relations as relations of recognition. As argued earlier, whether ‘ideological’ or ‘genuine’, if the relations in question are to be relations of recognition then the individuals concerned must feel valued for who they are, and be able to see existing relations as contributing to their personal growth and fulfilment. In this sense the distinction between ideological and genuine recognition cannot be drawn using the notion of ‘willing subjection’. What this notion brings to light are the very real, and very deep, disagreements in beliefs, values, social roles, and life goals that exist across contexts and ideologies. And while it certainly is of importance to debate and negotiate these differences, in order for such disagreements not to end up themselves generating conditions for misrecognition, it is necessary not to lose sight of the individuals involved, including their take on what they are doing and their experience of freedom and wellbeing.

Response to Order/Disorder, Kai Syng Tan’s UCL Institute of Advanced Studies Talking Points Seminar

5th December 2017

Title of seminar:

Order/Disorder – The artist-researcher as connector-disrupter-running messenger? 

by Dr Kai Syng Tan

My response:

Thank you very much for inviting me today.

I was pleased when I received this invitation, not only because it meant I can return to the IAS where I spent a year a couple of years ago, but because Kai’s work is hugely important, as well as being relevant to my work in philosophy and psychiatry.

For too long there has been a gap between, on one hand, social and professional understandings of mental health conditions and, on the other, individuals’ own understanding of their experiences and situation. There wasn’t much of a conversation going on, or if there was, it was framed in terms that emphasise disorder and deficit.

For some time, activism in mental health has been trying to change this, by demanding that people are heard on their own terms.

But then how do we bridge this gap, how do we create the possibility for generating shared understandings of the various mental health conditions? Just what do we to do? Well, we do what Kai is doing: inventive projects that bring people together, engage them in creative activities that unsettle some of their assumptions and broaden their  understanding, perhaps even their sense of empathy. For this kind of progress, it is not sufficient to give people information; they need to have an experience, and as I see it, Kai’s work provides both. 

*

There is a point I would like to make and to have your opinion on: it has to do with the distinction between order and disorder.

I came to this distinction first as a doctor and then as a researcher in philosophy and psychiatry. In philosophy, the concept of mental disorder has been the subject of many search and destroy as well as rescue missions over the past twenty-five years.

The key point of contention was whether or not we can define disorder (or more precisely, dysfunction) in purely factual terms, for instance as the breakdown of the natural functions of psychological mechanisms. The goal in such attempts was to define dysfunction in terms that do not involve value-judgements.

These attempts were not successful: at some point in the process of describing the relevant mechanisms and their functions, value-judgements sneak in.

Now demonstrating the value-ladenness of the concept of disorder does not mean that it suddenly disappears; and it does not mean that the boundary between order and disorder vanishes into thin air. It just means that it has become a much more controversial boundary than previously thought, and the distinctions it involves are difficult ones to make.

My point is that making qualitative distinctions among behaviours and experiences – whether our own or other people’s – is not optional: it is part of how we understand ourselves and understand others as psychological and social beings. 

That being said: even if the distinction between order and disorder – or between whatever terms you wish to use – even if that distinction is inevitable, it is one that we continually ought to attempt to transcend.

 Why should we attempt to overcome it? Because there might be order in what appears to be disorder, and disorder in what appears to be order; because in attempting to transcend this distinction we can grasp what it is that we share with others and not just what sets us apart; and because there’s no telling on which side of that distinction any of us is going to fall one day.

 It is precisely this paradox that we need to be conscious off and work with: the paradox of accepting the inevitability of a distinction while at the very same time seeking to transcend it. And I wonder what you think of this?

*

The other point I want to make has to do with the relation between our research and the activism that is connected to it. I must admit that in my own work I’ve frequently thought about this but I have not yet arrived at a satisfactory view. The question of course is broader than our area of research and applies to the humanities in general: to what extent should a researcher commit to the social cause they are researching, and what does this mean for the objectivity of what they are producing. What kind of balance do we need to strike here? And have you thought about this in your work?

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.

In Defence of Madness: The Problem of Disability

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

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

You can read the essay here: IN DEFENCE OF MADNESS

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

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

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

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

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

Mental Disorder: Separating Empirical From Conceptual Considerations

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

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

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

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

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

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

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

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

First critique: ‘Psychopathology is not first philosophy’

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

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

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

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

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

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

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

Second critique: ‘Distinguishing methodological from ethical value’

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

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

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

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

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

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

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

Mohammed Abouelleil Rashed – May 2015

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

Article published in Theoretical Medicine & Bioethics 2015

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

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

Mohammed Abouelleil Rashed   2015

Islamic Perspectives on Psychiatric Ethics

My chapter published online at Oxford Handbooks.

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

Abstract

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

Click HERE for Pre-Production version

Why I no longer believe in Revolution

 

Back in the summer of 2013 when Turkey’s Taksim square protests were at their height, I recall watching a reporter interviewing a protestor to the background of teargas smoke and fervent chanting against the government. The protestor unflinchingly and passionately declared that they are all here demanding their freedom from the dictatorial state. The effect of this whole scene on me was no less than visceral: I felt sick in that way you do when a cliché of massive proportions is unleashed upon you or, even better, when your interlocutor’s moral high-ground is so high – and so delusional – that your natural response, were you not mildly disposed, would be to punch him in the face. Revolution. I no longer believe in Revolution. In fact, I am positively opposed to it, to that irrational impulse to ‘occupy’ the Square and engage in fake unity over idealistic demands with people who in any other context you would normally reject the very idea of spending a minute with, and not only because you find them morally reprehensible. How did this happen; how have I become so anti-Revolution?

 

It wasn’t always like this. On the 26th of January 2011, a day after the Egyptian Revolution had started in earnest and Tahrir Square was definitely ‘occupied by the People’, I booked a flight from my London abode and flew to Cairo to take part in what I described at the time as “the most significant moment in my life so far”. Together with my ‘fellow’ Egyptians we occupied the Square, our chants developing from the usual concoction of Bread, Freedom, and Social Justice to the comically simply and reductive howwa yemshi mesh hanemshi: He (Mubarak) must go, we won’t go. And he went. On the 11th of February 2011, in what we would later understand to have been a sort of internal Coup against Mubarak, a thirty second announcement was delivered by the late General Omar Suleiman – then head of the Secret Service – declaring that Mubarak had waived his powers to the Supreme Council of the Armed Forces (SCAF).

 

Right after returning to London I wrote in an intense state my account of eleven days in Tahrir Square and published it in Anthropology Today. The article was a success: it became one of the most read articles in that journal for 2011 . I was contacted by a South American – Nicaraguan – Revolutionary journal for permission to have it translated into Spanish and in June of the same year it was published in Envio. The South Americans, of course, being for people of my generation the quintessential Revolutionaries. Yet on reading my account now I have the exact visceral response I had to the Taksim Square protestors: I feel sick – and embarrassed. There is an unmistakable sense of innocence, passion – and delusion – that jumps at you from the page when you read my account of the occupation of Tahrir Square. We were all One. You would see Westernised Egyptian girls, their hair flowing, conversing and agreeing with bearded Salafi men in their white robes. Rich Egyptians sharing a spot and a glass of tea with the destitute inhabitants of Cairo’s slums on the by now eroded grass of the Square. Egyptians, famous for being organisationally and aesthetically challenged, forming neat queues and cleaning the Square to prove to the State that we can do it. We were all united and on our best behaviour. The corrupt state – Mubarak and his henchmen – were the enemy and we were, unquestionably to us, worthy occupiers of the moral high ground. If they would just go, we the People will set it right. And this was and remains the crux of the problem with Tahrir Square and with Revolution in general.

 

What happened next is well known and extensively analysed. In a number of perceptive articles, Egyptian writer Youssef Rakha eloquently documented and devastated the charade that is the Egyptian Revolution. By October 2011, when tens of Coptic protestors were murdered at Maspiro by security forces, and in the ensuing fabrications constructed by certain ‘fellow’ Egyptians to blame the Copts, I became acutely aware that the unity of Tahrir square was nothing but a temporary delusion: we were never One. We were always divided by class, education, belief, ideology, gender, geography, by our capacity for reason and our integrity: how did I ever think otherwise? Throughout the months in which SCAF were the explicit rulers of the country, they methodically destroyed the possibility of a reasonable transition to a reasonable government. Presidential elections conducted in June 2012 brought to power Muhammad Morsi of the Muslim Brotherhood who after a series of political blunders, mismanagement, and opposition by key state institutions was overthrown, having spent only twelve months in office, in what can only be described as a CoupVolution: it was not merely a Coup, and it certainly wasn’t a pure outcome of People Power. A few months after that and we were back pretty much to where it all started: an army general as our new president, having resigned from his position as head of SCAF. With the media resuming their familiar role of leader-worship and the country bitterly divided; with the space for expressing opinion severely restricted, and the political discourse reduced to name-calling and falsehood; with two presidents on trial and thousands of political prisoners; with intolerance, religious dogma, and harassment right there on the surface of society, it’s no wonder that I and many people like me are painfully disillusioned. From those heady days of the Square to the situation we are in today: now that’s quite a fall.

 

What is wrong with Revolution? One of the more obvious criticisms is that Revolution can only be destructive. The collective uprising that is Revolution occurs because there is no political process capable of responding to peoples’ grievances and needs. The People rise and forcefully articulate what they do not want, but, naturally, they have nothing else to replace it with, nothing substantial or meaningful that is. And this is not a coincidence. What is required for there to be a political vision by which alternatives to the existing system can be conceived, is a political process capable of generating this vision. But Revolution is an outcome of the absence of such a process, it therefore can offer no serious alternative to replace the machinery of the State it is so intent on bringing down. A quickly cobbled together system of ‘government’ that is in actuality a disguised sectarian ideology or, in other words, the Muslim Brotherhood, does not qualify for a viable political system. In fact, in the case of Egypt, it almost brought the country to the brink of total collapse. Further, the demand for Bread, Freedom and Social Justice may appear, contra to my claim, a positive rather than a destructive demand. But how can this demand ever be realised in the absence of the State? If the People want material equality, freedom and respect, their hope of realising any of this is within the confines of a functioning State. The State may fail miserably on all these dimensions, but the very demand for equality, freedom and respect presupposes an existing structure of which such demands can be made. Things, then, seem much more serious than the average Placard Holding, Tear-Gas Fighting, Square Occupying, Freedom Demanding protestor seems to appreciate. And to realise that I, by virtue of participating in the Revolution, am also guilty of this phenomenal and dangerous naivety.

 

I might be accused of being too pessimistic and short-sighted. Revolution, the thought may proceed, can only be judged like other major events of this kind with the benefit of hindsight once seen as part of broader historical changes. The long-term consequences of Revolution will only be palpable several decades down the line. Might it not have been the case that certain French individuals at the height of the French Revolution in the late 18th century were also, like me, disillusioned with the idea of Revolution? And weren’t they too myopic and ill disposed to see that the French Revolution was a first step on a long road to Democracy, the system of government now generally considered infinitely preferable to absolute Monarchy? Now this is an important argument and I concede that it is not possible to be cognizant of the future desirable consequences of such social upheaval. But that’s precisely the problem. We consider Democracy desirable because our values and perspectives have changed from those of the 18th century. From where we stand now, for many of us at least, it is difficult to desire a form of government that is entirely undemocratic. But the point of interrogating the rightness of an act, in this case of Revolution, is to interrogate it with what I have at my disposal now; with what I know now and not what I would know given the resources available through some hypothetical future. Revolution is a powerful social phenomenon with consequences beyond our capacity now to fathom, but the point is to know how we should position ourselves in relation to it as moral agents living in this age and place, right now, right here. And it is my contention that Revolution should be resisted because, paradoxically, it is a mechanism which guarantees that no change will actually happen where it matters.

 

Revolution is premised on a fundamental lack of integrity. Even more, Revolution is essentially defined by a worldview which is so morally unambiguous and transparent only because it traffics in one of the more extreme acts of self-deception a person can commit, short of outright insanity. Revolution is not morally discerning or subtle: there is ‘us’ and we are good; and there is ‘them’ and they are evil. A worldview so simple and reductive that in any other situation we would severely reprimand its holder – if not feel pity for him – whereas with Revolution we actively embrace it, shedding with it our cognitive and moral integrity. In apportioning all blame to a circumscribed entity – variously the State, Mubarak, the National Democratic Party, or the Muslim Brotherhood – the Revolutionary is thus free to plumb the depths of victimhood, shielding himself from all possibilities for self-examination. And that would have been bad enough if no serious consequences followed from this collective act of self-deception. But it is precisely this self-deception that makes it appear to the Revolutionary that one thing must happen, and must happen now, which is for the identified guilty political entity to be dismantled. And what happens next? Having no alternative system to replace the outgoing one, what gradually but inevitably occurs is for that outgoing system to return, only rearranged and cosmetically altered. This is not due to some underlying conspiracy, or even due to the failure of the Revolution; this is precisely the purpose of Revolution: a sort of rearrangement of the same political and social structure which existed before. Revolution is a trick, the purpose of which is to recycle society rather than genuinely change it. Revolution is conservative; Tradition in spectacular garb.

 

Joseph de Maistre famously wrote that “every nation gets the government it deserves”. While he was referring to the choices people make within a democracy, his epigram can equally be applied to autocracies where people apparently have no choice in who governs. Now that may sound counter-intuitive, after all how can I deserve that which I have not chosen? How can anyone, to be more specific, deserve a Gaddafi or an Assad? But tyrants don’t just descend upon us from nowhere. We create tyrants as much as we create democrats and both have to be ultimately accounted for in terms of the people whom they govern. In order to stop getting ‘what we deserve’, we must stop projecting the worst that is in us and receiving it back in the form of a Mubarak or a Sisi, then rising against them in an impotent act – Revolution – only to find, when the dust has settled, that nothing has changed. By reflecting, each one of us, on his and her place in the social fabric, we can begin to perceive the part we play in that ugly and fractured society we are so keen to change yet are unwilling to take responsibility for. It is not so much a case of the unashamedly romantic “be the change you want to see in the world”, rather, it is the more sober: if you want to see change in the world then you better start by looking at yourself.

 

Mohammed Abouelleil Rashed  

August 2014

PDF file of this essay

Can Psychiatry Distinguish Social Deviance from Mental Disorder?

[NOTE: (May 2015) Essay and commentaries are now out in print: Click HERE]

Essay accepted for publication in the journal Philosophy, Psychiatry and Psychology

Written with Dr Rachel Bingham

Abstract and excerpt.

Abstract: Can psychiatry distinguish social deviance from mental disorder? Historical and recent abuses of psychiatry indicate that this is an important question to address. Typically, the deviance/disorder distinction has been made, conceptually, on the basis of dysfunction. Challenges to naturalistic accounts of dysfunction suggest that it is time to adopt an alternative strategy to draw the deviance/disorder distinction. This article adopts and follows through such a strategy, which is to draw the distinction in terms of the origins of distress with the relevant conditions. It is argued that psychiatry’s ability to distinguish deviance from disorder rests on the ability to define, identify and exclude socially constituted forms of distress. These should lie outside the purview of candidacy for mental disorder. In pursuing this argument, the article provides an analysis of the social origins of a form of distress with the personality and sexual disorders, and indicates in what ways it is socially constituted.

Keywords: Distress; Dysfunction; DSM-5; Cognitive Dissonance; Sexual Disorders; Personality Disorders

CAN PSYCHIATRY DISTINGUISH SOCIAL DEVIANCE FROM MENTAL DISORDER?

INTRODUCTION A number of leading figures in psychiatric nosology and the philosophy of mental health proposed various changes to the definition of mental disorder (Stein et al. 2010). These changes were intended to guide the development of the definition in the now published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5. The authors proposed the following criteria which develop those in the DSM-IV (APA 1994); a mental disorder is:

  1. A behavioural or psychological syndrome or pattern that occurs in an individual
  2. the consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning).
  3. must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)
  4. that reflects an underlying psychobiological dysfunction
  5. that is not solely a result of social deviance or conflicts with society

In this article we consider criterion E, an exclusionary criterion intended to safeguard against pathologising social deviance and imparting diagnoses on the basis of discrimination. The importance of this safeguard cannot be overstated. The distant as well as recent history of psychiatry is replete with instances of the abuse of diagnosis and treatment for political purposes (van Voren 2010). And psychiatry tends to be susceptible to the claim that it functions as a tool for social control, disposing of ‘problematic’ individuals under the justification of a medical diagnosis (Szasz 1998).  It has been argued for some time that abuses of psychiatry do not require mal-intent on the part of clinicians, but happen despite psychiatrists involved believing their diagnoses to be valid (van Voren 2002). Fulford, Smirnov and Snow (1993, 801) suggest that corruption, political pressures, poor clinical standards and a lack of safeguards “explain the ‘how’ but not the ‘why’ of abuse”. The authors argue that conceptual issues – in particular failure to recognise the value-laden nature of psychiatric diagnoses – explains the “why”, and leaves psychiatry particularly vulnerable to abuse. Elsewhere, the need to address past abuses of psychiatry was argued to require a satisfactory definition of ‘mental disorder’ (Wakefield 1992). Antipsychiatrists did not agree with this diagnosis. Following Thomas Szasz’s seminal argument that mental illness is a ‘myth’, the conceptual foundation of psychiatry has been strenuously disputed. Conceptual issues were not, for Szasz, the root of abuses, but rather legitimised them:

[W]hile de jure, the mental hospital system functions as an arm of the medical profession, de facto, it functions as an arm of the state’s law-enforcement system. The practices thus authorized do not represent the abuses of psychiatry; on the contrary, they represent the proper uses of psychiatry, sanctioned by tradition, science, medicine, law, custom, and common sense. (Szasz 2000, 11-12)

This is an articulation of the concern, or allegation, to which Criterion E responds. In the past, the scholarly defence has been to argue, in various ways, that psychiatry is in fact able to recognise and define its proper domain, thus the question of what is a mental disorder is central to the debate. Criterion E offers both an official recognition of the dangers of pathologisation and an apparent conceptual safeguard. This paper does not further rehearse the debate about the need for such a safeguard, but explores whether Criterion E is able to fulfil this role. Thus our contribution is to update the debate in the light of recent work on concepts of health and illness, to try to make the distinction between social deviance and mental disorder using DSM-5, and to provide an original analysis of the social origins of some forms of distress in the light of these considerations.[i]

In order to explore what criterion E entails we revert to the full definition provided in the now published DSM-5: “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual” (emphasis added). [ii] This is almost identical to the definition provided in the DSM-IV. Thus formulated, as Stein and colleagues (2010, 1765) note in relation to the DSM-IV, criterion E is not “strictly necessary” as the prior specification (criterion ‘D’) that the condition or syndrome must be due to a dysfunction in the individual suffices. However, given the aforementioned importance of guarding against misuse of psychiatry for political or other discriminatory purposes and the difficulty in indicating appropriate use of the term ‘dysfunction’, Stein and colleagues chose to retain criterion E in simplified form. Conceptually, then, if a dysfunction can be identified then a mental disorder can be said to be present if the other criteria are also fulfilled. The safeguard against pathologising social deviance is accordingly the identification of dysfunction in the individual. Thus although presented as a criterion required by the conceptual and empirical difficulties inherent in defining and identifying dysfunction, to do any work criterion E in fact depends on the ability to define and identify dysfunction.

This article proceeds as follows: First, we identify some relevant meanings of ‘dysfunction’ with a particular focus on dysfunction understood in terms of the consequences of a syndrome: distress and disability. Second, we examine the implications for criterion E of understanding dysfunction in those terms. We argue that distinguishing social deviance from mental disorder now requires that a distinction is drawn between phenomena in which distress is an outcome of social conflict and discrimination and phenomena in which distress is intrinsic to the condition. Third, we explore different meanings of ‘intrinsic’ distress. We point out the difficulty in providing a positive definition and focus thus on what ‘intrinsic’ is not rather than on what it is. We propose that an alternative to distress being intrinsic to a condition is for such states to be constituted by social factors. What does it mean for distress to be constituted by social factors? To answer this question we explore the difference between factors that may cause a distressing state and factors that constitute that state.  We argue that psychological states that are socially constituted – that is, are created and sustained by social factors – are excluded by criterion E from candidacy for mental disorder. Fourth, we provide an account of distress with the conditions of most relevance to the distinction between social deviance and mental disorder, pointing out in what ways distress may be understood as socially constituted. Fifth, and finally, we present some clarifications and outline some implications of this view. This article considers only Criterion E, and not the other criteria for a mental disorder as listed above. Thus, a condition that is argued to meet Criterion E may yet fail the other criteria and therefore not be considered a mental disorder under the DSM definition, despite meeting the final criterion.

DYSFUNCTION

As indicated in the introduction, to do any work criterion E depends on defining and identifying dysfunction. A reasonable starting point, then, would be to attempt to specify the meaning of the term ‘dysfunction’.  One prominent strategy has been to seek a definition of dysfunction in naturalistic terms. The most widely debated and influential has been Jerome Wakefield’s evolutionary theoretic approach (1999, 1997). According to Wakefield, a dysfunction is a result of some mechanism failing to perform its natural function as designed (selected) by evolution (i.e. the function that can explain why the mechanism or organ exists and why it is designed the way it is). Wakefield’s account has been criticised as highly speculative and lacking in clinical utility. Further, it appears to rely on the questionable assumption “that there is a clear (enough) division between psychological functioning that is natural (evolved and innate), as opposed to social (cultivated)” (Bolton 2008, 124). In the absence of a clear division, Wakefield’s dysfunction cannot tag exclusively onto a fact of nature, precisely because psychological function is the product of “several interweaving” natural, social, and individual factors which are not separable through the science we currently possess (Bolton 2010, 329-331).

Problems with Wakefield’s account and with naturalism more generally have prompted alternative strategies to understand dysfunction.[iii] Thus, Bolton argues, if we abandon naturalism about illness, “if we give up trying to conceptually locate a natural fact of the matter 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). Stein and colleagues note that an alternative to naturalism is to understand ‘dysfunction’ in terms of the “consequences of the syndrome, specifically that it leads to or is associated with distress and disability” (2010, 1763, emphasis added).  The move from ‘naturalism about illness’ to ‘distress and disability as the mark of illness’ is a reversal of the priority of dysfunction from being antecedent to the syndrome to being a manifestation, or consequence, of it. For example, what marks out a syndrome like depression as illness is not some underlying and invariant psychological or biological mechanism(s) but the subjective experience of distress and the extent of impairment of the person’s day to day functioning. This is consistent with the syndrome being caused or constituted by biological factors: this reversal does not entail the denial of biology. What it indicates is that illness attributions, conceptually, cannot be made on the basis of an antecedent natural fact, but on the basis of the consequences of the syndrome as they manifest for the subject. This raises a further complexity in terms of which kinds of distress are to be conceived as illness as opposed to a normal response to the vicissitudes of life. We leave this complexity aside and stay with the original point: to do any work criterion E depends on defining and identifying dysfunction. Now that ‘dysfunction’ is understood in terms of the consequences of the syndrome, viz. distress and disability, could it be claimed that the identification of distress and disability is sufficient ground to diagnose mental disorder irrespective of social deviance or conflict? The answer to this question clearly is no. The reason is that distress and disability may be an outcome of social deviance and conflict, while they also may not. If we wish to ensure that diagnosis is not inappropriately applied to individuals whose suffering can, in some relevant and significant sense, be understood as a consequence or expression of conflict with society, then it becomes necessary to draw this distinction.

[i] A reviewer for this paper had made the important point that the distinction between mental disorder and social deviance is itself a cultural construction with a long history. This suggests that there is scope to deconstruct the distinction. While clearly an interesting project in its own right, our concerns here are more limited to exploring whether – through criterion E – the distinction can be made. We thus assume that there is something called mental disorder or mental health problem (definitions of which are subject to much debate), and something called social deviance (which has nothing directly to do with mental disorder). We further assume that this is an important distinction to make. [ii] DSM-5. The definition of Criterion E in the DSM-IV: “neither deviant behaviour (e.g. political, religious or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual” (APA 2000, p. xxxi). [iii] See Bolton (2008, 2013) and Kingma (2013) for review and critical assessment of the various attempts to define dysfunction in naturalistic terms.

Spirit Possession, Personhood, & Intentionality: Perspectives for the Philosophy of Mental Health

Summary of an essay I completed recently.

Spirit possession is a common phenomenon around the world in which a non-corporeal agent is involved with a human host. This manifests in a range of maladies or in displacement of the host’s agency and identity. Prompted by engagement with the phenomenon in Africa, this paper draws some connections between spirit possession, and the concepts of personhood and intentionality. It employs these concepts to articulate spirit possession, while also developing the intentional stance as formulated by Daniel Dennett. It argues for an understanding of spirit possession as the spirit stance: an intentional strategy that aims at predicting and explaining behaviour by ascribing to an agent (the spirit) beliefs and desires, but is only deployed once the mental states and activity of the subject (the person) fail specific normative distinctions. Applied to behaviours which are generally taken to signal ‘madness’ or ‘mental illness’, the spirit stance preserves a peculiar form of intentionality where otherwise behaviour would be explained as consequence of a broken physical mechanism. Centuries before the modern disciplines of psychoanalysis and phenomenological-psychopathology endeavoured to restore meaning to ‘madness’, the social institution of spirit possession had been preserving the intentionality of socially deviant behaviour.

Discuss: If critical psychiatrists had scientifically valid and convincing arguments, psychiatrists would agree with their position

(Discussion initiated by Patrick Allen)

Critical psychiatrists make – at least – four claims:

  •  Psychotropic drugs are harmful.
  • Mental health conditions are problems in living a la Thomas Szasz: they are not illnesses.
  • Psychiatry medicalises human experience and suffering.
  • Psychiatry is in cahoots with ‘Big Pharma’ which partially provides the incentive for the previous three problems: more harmful drugs, a disease model of human experience and suffering, and the increasing medicalisation of the same.

I accept that different critical psychiatrists may hold these claims with various degrees of conviction, but these four claims are a good starting point. To address the point of debate – “If critical psychiatrists had scientifically valid and convincing arguments, psychiatrists would agree with their position” – we need to assess each of these claims. If they are valid then psychiatrists should agree. Let us first state the (obvious) point that agreement or lack thereof is not the sole consideration for the validity of a position. The point of debate should rather be: are the arguments of critical psychiatrists valid? In any case, with this minor point aside we can turn to more substantive concerns. I’ll just sketch some of the issues here.

  • Psychotropic drugs are harmful: this is clearly an empirical claim and I am not an expert on the evidence here. But there seems to be loud voices from consumers of psychiatric drugs and psychiatrists alike who have compelling evidence (including first-person experience) that the side-effects of psychiatric drugs are serious (think of Clozapine for instance) and the therapeutic effects poorly understood. On that basis, if only tentatively, we can grant the critical psychiatrists the first point. But it should be qualified by saying that some people benefit from psychotropics and swear by them.
  • Mental health conditions are problems in living a la Thomas Szasz: they are not illnesses: this is a conceptual point and has been much debated over the past twenty years in the philosophy of psychiatry. Basically, the issue turns on how we define illness or disorder. I am obviously not going to go in to that long debate but I personally find convincing that a central feature of illness is a negatively evaluated experience of incapacity where incapacity is defined as the failure of intentional action (see the work of Bill Fulford and Derek Bolton, although Derek adopts different terminology).  And this central feature can apply equally to the conditions we call physical as to those we call mental. In short, whether or not mental conditions are illnesses depends on how we define illness. Therefore, I would not grant critical psychiatrists the second point.
  • Psychiatry medicalises human experience and suffering: Yes, psychiatry does do that: many behaviours including sexual have become ‘addictions’ and ‘disorders’; mischievous, active children have ADHD; sadness is depressive disorder; and so on… So it is true that psychiatry is engaged in medicalisation. And this clearly can be a bad thing, for instance in the loss of diversity and authenticity that ensues from transforming the human condition to broken mechanism. But not everyone would take this view, some would not consider medicalisation a negative thing. There seems to be deeply held values at play here pertaining to the meaning of our experiences and our lives more generally. Thus, I would agree with the critical psychiatrists that psychiatry medicalises human experience, but would leave the issue of medicalisation – whether it is bad or not – a point for debate. Hence, I would not grant critical psychiatrists the third point.
  • Psychiatry is in cahoots with ‘Big Pharma’: Seems likely! There is a wealth of evidence supporting this point. And if it is true, this really is a problem as it jeopardises the scientific integrity and ethical standing of psychiatry. I therefore grant the critical psychiatrists the fourth point.

So, the score is 2 for and 2 against! I’ll leave it at this.

Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence & its practical application

Click here for article

Culture, salience, and psychiatric diagnosis: exploring the concept of cultural congruence & its practical application. Philosophy, Ethics and Humanities in Medicine (Journal)

This article is part of the series: Towards a new psychiatry: Philosophical and ethical issues in classification, diagnosis and care

Abstract

Cultural congruence is the idea that to the extent a belief or experience is culturally shared it is not to feature in a diagnostic judgement, irrespective of its resemblance to psychiatric pathology. This rests on the argument that since deviation from norms is central to diagnosis, and since what counts as deviation is relative to context, assessing the degree of fit between mental states and cultural norms is crucial. Various problems beset the cultural congruence construct including impoverished definitions of culture as religious, national or ethnic group and of congruence as validation by that group. This article attempts to address these shortcomings to arrive at a cogent construct.

The article distinguishes symbolic from phenomenological conceptions of culture, the latter expanded upon through two sources: Husserl’s phenomenological analysis of background intentionality and neuropsychological literature on salience. It is argued that culture is not limited to symbolic presuppositions and shapes subjects’ experiential dispositions. This conception is deployed to re-examine the meaning of (in)congruence. The main argument is that a significant, since foundational, deviation from culture is not from a value or belief but from culturally-instilled experiential dispositions, in what is salient to an individual in a particular context.

Applying the concept of cultural congruence must not be limited to assessing violations of the symbolic order and must consider alignment with or deviations from culturally-instilled experiential dispositions. By virtue of being foundational to a shared experience of the world, such dispositions are more accurate indicators of potential vulnerability. Notwithstanding problems of access and expertise, clinical practice should aim to accommodate this richer meaning of cultural congruence.

THE DOGMA IS DEAD! LONG LIVE THE DOGMA!

Ideas, like their bearers, pass through several stages unto death. They start life as solutions to practical problems and, if they endure, sediment as inviolable truths about the world. These truths may take on an ethical significance and the ideas become binding moral imperatives. Ideas are born pragmatic, their coming-of-age is positivist, and their maturity lies in a mysteriously compelling normativity. Perpetually and surely, ideas progress towards death, a death that we call ‘reality’. We do not allow ideas to die, we resurrect them by keeping them part of that most concrete of things: reality, the archaeological sediment of centuries of ideas; what our great relatives and their ancestors have thought up to control the world and each other. An idea is most relevant and immediate when it is born, when it still has an intimate relationship to the practical circumstances it arose to address. In time, the material and social conditions change and ideas must change with them. But many ideas persist and we, seemingly oblivious to their death, allow them to remain in our cognition much like mummified relics or, in a word, dogma.

*

To be free of dogma is to realise when an idea has died. Dogma is death, the death of ideas. For an idea only rises to the status of dogma when it presents itself as that which it is not: as ‘truth’ or ‘reality’ or the ‘good’ as opposed to that which it was: a solution to a problem somewhere in the past, a problem that no longer exists but for which the idea continues to present a ‘solution’. Dogma recreates the original problem, in order to present itself as the only solution.

*

Religion in the 21st century is pure dogma. The ideas that constitute organised, prescriptive, a-spiritual religion have served their purpose. Religion has nothing to offer but a limitation on thought and a constraint on morality. It tells us what we cannot think; it delineates the limits of thought. Religion tells us what we should do in a world that is different to the one where its precepts were first formulated. A sceptic questions a grand ideology that purports to explain everything without ever doubting itself. Religious dogma tells us that a woman’s body is sinful, it needs to be hidden and covered, and this is presented to us as an entirely natural and self-evident truth; a real and genuine problem. Religious dogma recreates a problem – the woman’s body – in order to offer a solution: a host of limitations on women’s freedom. And it doesn’t matter if women endorse the dogma willingly or if they believe that by covering themselves they will go to heaven. It doesn’t matter because they too are allowing the dead ideas of religion to persist among us: they too are guilty of this perpetual resurrection.

*

Scepticism is the mirror that confronts the idea with the image of its own death. Scepticism frees us of dogma, and allows us to align ideas with the social and material world surrounding us.  A sceptic questions the basis of an idea, its raison d’être. A sceptic is not scared by an idea’s claim to truth or goodness; he can see beyond this, he can see that it is dead: a sediment.

*

For many decades now and we have had the foundations to live without an eternal guarantor. Unlike Descartes for whom the world was unimaginable, unthinkable without a mighty Agent overseeing its Truth. We no longer need God. It is not that we have, necessarily, ceased to believe in Him (even if some of us think admitting this is crucial), nor that we feel compelled to prove His non-existence – as atheists are inclined to do, no: we just no longer need him; much like a toddler no longer needs a walking-brace once his legs can carry him. We can tolerate a sense of ‘fundamental insecurity’, we can tolerate ‘existential angst’ – in short, we can tolerate life without God. And none of this is new: this is the legacy of the enlightenment, and has been with us, with a particular laity that is, for centuries. It is no longer unusual – let alone heroic – to forsake God.

*

Throughout the enlightenment, the idea that religion is a necessary condition of meaning-fullness gradually declined, and a slowly emerging humanism began to fill its place. This was not easy. Descartes, the first of the modern, radical sceptics, went as far as the cogito. But he ended up preserving God, the guarantor against falsehood and the protector from nihilism. Nietzsche’s madman roamed the streets declaring the death of God, only for the philosopher himself to die, in the most ironic of predicaments, in the midst of syphilitic insanity. In time, the conditions for a genuine secularity were laid down and human beings were able to seek fullness and meaning without the need for God.

*

Religious political parties are agents of death; they traffic in the dead ideas of religion. And they are only able to do so because we, the People, have allowed these ideas to persist among us; we have continually resurrected them. By capitulating on our failure to eradicate dogma, Religious parties secure power and wield it upon us the willing and thankful people.

*

Have we, Heirs of the Enlightenment, rid ourselves of dogma? Have we trained ourselves to see ideas through the lens of pragmatism? Liberty, Equal Opportunities, Human Rights, Individualism, Freedom of Speech. These are just a few of the ideas that have become our lingua-franca. They are, or have become, self-evident truths. While John Stuart Mill might have had to argue for Liberty, we no longer need to. Evidently, it seems, these ideas represent a massive leap over religious dogma: they reflect a more inclusive society and broader possibilities for human flourishing. But are these ideas beginning to exert a hold on us that exceeds the hold of expediency? Are they, that is, progressing slowly towards death?

*

It’s a story we are all familiar with now: we live in the midst of an aggressive Individualism. Our value system is struggling to define itself independently of the ethos of consumption. We struggle against this but are always driven back by sheer momentum but also by bottomless greed. And then we are faced with fundamental inequalities, and many tell us that that is fine; that is the way it should be. We all have Equal Opportunities, the dogma goes, so you have only yourself to blame when your share of the material world doesn’t match your expectation or your needs: each to his own. And not only do we no longer need to justify the primacy of Liberty, no, some of us are prepared to kill others to bequeath upon them that most precious of our discoveries: Freedom. And you can talk, you can denigrate others, you can burn books like they did in the Middle-Ages and we will call it Free Speech. The rot at the core of enlightenment ideology is rapidly spreading and the stench is becoming unbearable.

*

Freedom of Speech, Individualism, Liberty, Equal Opportunities: dogmas rapidly approaching death. To free itself of thousands of years of Pharaohs, Sultans, Kings and Lords humanity had to discover the individual. It had to enshrine the rights of each and every person, not in order to worship them, but by way of expediency: a solution to the problem of absolute power. Now, these ideas have lost their pragmatic value: they are no longer responding to a practical need. Absolute power is no longer in the hands of the Monarchs; power is in our hands. But we squander it willingly to those gigantic entities that manufacture our desires while also selling us their satisfaction. Individual rights and Liberty have become the justification for the status quo: they have become ideals that no longer limit absolute power but create it.

*

Some of us can see that the dogma of the enlightenment and the status quo which it now creates are not sustainable. We are told that we are using up the planet’s resources; melting the poles; raising the temperatures. And if we do not do something about it, many of us will die not so far from now. And this indeed might appear as a highly pragmatic set of ideas. There is a problem, we need to address it, and this is how we do so. But… already, we can hear those who want to raise those ideas to the status of ethical imperatives. They are not content with the issue being a pragmatic issue which should be addressed, they want to transform the ideas into dogma, and thereby move them faster along the path of their inevitable destruction; towards their death. And we must resist this; we must insist that the connection between an idea and the practical need it arose to address is not lost. Because if we do not do so we will join the chorus of humanity in that famous call that echoes from the dark ages and has not yet left us: The dogma is dead! Long live the dogma!

Mohammed Abouelleil Rashed   2012

Abstract for the 15th International Philosophy & Psychiatry Conference: July 2012: Safety in Numbers and Crazy Cultures: the Limits of Diagnosis

With Natalie Banner, Rachel Bingham, Norman Poole, Roman Pawar, and Abdi Sanati

Overview
This workshop considers the role of community in understandings of normality. In 1994, the DSM added a caveat to the definition of mental disorder, that cultural congruence protects individual’s beliefs and values from being labelled as pathological. This reflected a blossoming political and ideological notion of ‘tolerance’, which now underpins widespread efforts to respect – and not alienate – communities with non-mainstream value systems and beliefs. The INPP 2012 conference reflects continued efforts to understand and embrace difference and promote tolerance. Yet, mental disorder is fundamentally about ‘difference’, and is by definition not tolerated but treated. We therefore propose the following presentations in an exploration of ‘difference’ as it arises within, and between, communities. The first presentation questions why it is that a single individual with an unshakable and dangerous value system may sometimes be diagnosed with a mental disorder, while an unshakable and dangerous value system held by a group may be criminal, but is not ‘pathological’. The second presentation considers the features of communities which protect against diagnosis. We consider the dependence of this immunity on being sufficiently  organised and having a discourse and dialogue of acceptability or tolerance. The final presentation discusses the successes of the homosexual civil rights movement in establishing a respected orientation as opposed to a repressed medical condition. We consider the conceptual problems illuminated by this shift, which reveal important features of diagnosis itself.

Relevant links:

INPP Conference 2012 Website

Breivik Trial

Hearing Voices Movement

Pro-Ana Blog