Best of 2018 Philosophy List by Oxford University Press

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

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

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

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

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.

COMPLEXITIES FOR PSYCHIATRY’S IDENTITY AS A MEDICAL SPECIALTY

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. In this post, I examine these complexities, asking whether or not they are fatal to psychiatry’s identity as a medical speciality.

Normative Complexity

When doctors refer to an organ or system not working as it should they do not intend this judgement in a moralistic sense; what they mean is that the organ or system is not functioning in the way they expect it to given the purpose for which it was designed, or that it is not functioning as it does for the majority of people in an appropriately defined population, or that its anatomy or histology is grossly distorted. These three naturalistic takes on dysfunction (which are not the only possible ones) correspond, respectively, to evolutionary theory, bio-statistical theory, and lesion theory. There is now a huge literature both in the philosophy of medicine and the philosophy of psychiatry on the concept of dysfunction and on the possibility of defining it in value-free terms (e.g. Boorse 2011; Bolton 2008, 2013a; Varga 2015; Kingma 2013). A key intuition driving this debate seems to be that if we cannot define dysfunction in value-free terms then it becomes harder to distinguish proper clinical judgement from the moralistic interjections of zealous clinicians. The debate continues and I will not venture into it, partly because it is not directly the subject of this post, and partly for the reason that in many cases that distinction does not really matter: clinical judgement and moralistic judgement collapse into each other when all parties are (broadly) in agreement that something is not working as it should, and that that thing is an appropriate target for medical intervention; i.e. there are known treatments and a known prognosis; it is a condition that doctors treat as opposed to, say, a spiritual malady. When disagreements arise, clinical and moralistic judgements come apart and clinical intervention is problematised. Note that from the perspective of the patient, the doctor’s alleged moralistic judgement can go both ways: the doctor can judge that you have an organ or a system that is not functioning as it should, whereas you think that it is; conversely, the doctor can judge that the organ or system is functioning as it should, whereas you think that it is not. In the former case you reject medical diagnosis and intervention, and in the latter case you seek them but they are denied. In addition, there is a variant of the first possibility where someone else – perhaps a relative – deems that something about you is not working as it should, a judgement with which the doctor agrees but which you reject.

As doctors and patients know, these possibilities for disagreement are not uncommon in medical practice. For example, you experience pain in your acromio-clavicular joints when you exercise; you visit an orthopaedic doctor who tells you that this is consistent with age: “there’s nothing wrong with you”, the doctor says, an explanation that you refuse to accept. Conversely, the doctor examines you and prescribes anti-hypertensive medication which you refuse to take as you feel well and do not believe that you have problems with your blood pressure. In psychiatry, discrepancies in judgements of this sort are more intractable, more common, and, given the power that psychiatrists have to detain individuals, more serious in their implications. This intractability arises from the fact that psychiatry deals with the mind not working as it should. The normative judgements involved in such a determination are more complex than those involved in determining, say, whether or not the ophthalmic system is working as it should. This complexity, in turn, creates considerable possibilities for disagreement. This is to be expected: belief, reasoning, emotion, and perception – to name a few faculties of mind – permit a wide range of evaluations and demonstrate a high degree of “observer-relativity” (Bolton and Hill 2004, p. 99; see also Bolton and Banner 2012, p. 83). To agree on what it is to have true belief, valid reasoning, appropriate emotion, and veridical perception is more complicated than it is to agree on what it is to have good visual acuity, even after we account for the fact that for a fighter pilot a 0.1 drop in vision is life-changing, whereas for a drummer it is not.

Negotiating the intractable disagreements that arise in psychiatric practice means that psychiatry, like – but more than – other medical specialities, has to be aware of differences in values among the various stakeholders, and of the cultural beliefs that constitute the profession itself as well as those that persons bring to the consultation. Given the magnitude of these challenges, it is not surprising that theoretical and now also practical endeavours have taken psychiatry as the paradigm case of the complexity of the clinical encounter and therefore also as the target for developing and testing solutions that can benefit clinical practice irrespective of specialty.[1] Far from undermining the identity of psychiatry as a medical speciality, the normative complexity inherent in psychiatry demonstrates that it shares the same problems other specialities have to deal with, only in psychiatry these problems are more common and challenging.

Explanatory Complexity

The subject matter of psychiatry is the ‘mind not working as it should’. As a medical speciality, psychiatry aims to relate the various failures of mind to underpinning biological substrates in the brain. One position in this respect is to reduce those failures to specific brain dysfunctions. Mental disorders, on this view, are nothing but brain disorders; as some authors have put it, “there are only brain disorders that psychiatrists prefer to treat and other brain disorders that neurologists (and neurosurgeons) prefer to treat” (Baker and Menken 2001). Biological reductionism goes back a long way; historians of medicine identify a shift to purely somatic explanations of ‘madness’ towards the end of the 19th century in Europe (e.g. Scull 1975), a shift that persists among some practitioners and researchers. Yet it is fair to say that biological reductionism is not a popular view today, with many practitioners and researchers adopting a multifactorial, non-reductionist view of causation of mental disorders, the well-known biopsychosocial model.

Non-reductionist views are held even by those who wish to end the distinction between mental disorders and brain disorders in favour of the latter. White and colleagues, for example, make a number of arguments in this regard, one of which is the empirical point that psychosocial factors “interact strongly” with neurological disorders, while “disorders of the mind are rooted in dysfunction of the brain” (White et al. 2012: 1). Their point is that psychological, social, and biological causal and risk factors run across all medical conditions, whether mental or physical. If so, then there might not be much sense insisting on the distinction between mental disorders and brain disorders, especially, they argue, in light of recent advances pertaining to the neurological and genetic bases of mental disorders. Part of the authors’ motivation in advancing this proposal is to foreground psychiatry’s identity as a medical speciality. This, they point out, can improve recruitment into the profession, for if psychiatry is more explicitly aligned with neurology it may become more attractive to medical students. On the other hand, a more medicalised psychiatry would be able to define more clearly its distinctive contribution to mental health care relative to allied professions such as clinical psychology and mental health social work. Standing in contrast to White and colleagues’ proposal is a position paper by Bracken and colleagues that advances a similarly non-reductionist position but rejects the suggested equivalence between psychiatry and neurology: “psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural  and psychological dimensions” (Bracken et al. 2012: 432).

There is no doubt that both mental and physical health conditions demonstrate “multifactorial pathways”, nevertheless psychosocial factors appear to be more prominent in mental disorders across a range of dimensions (Bolton 2013b: 25). To the extent that this is the case, psychiatry differs from many other medical specialties in that it “has particular expertise in the management of psychosocial factors as well as internal biological factors” (ibid.). One could take this observation to support the view that we should not collapse the distinction between mental disorders and brain disorders. Or one could decide that the terms of the debate are out of keeping with developments in the new mental health sciences. These “new sciences do not work with ideological battles between the biological, the psychological, and the social … rather they work with all of these factors and the diversity of interplay between them” (ibid.). There is much work to be done, both empirical and conceptual, to understand how the different social, psychological, and biological factors interact in specific conditions. However – and this is key – that work applies to physical health as well as mental health conditions (see, for example, Hernandez and Blazer 2006, and Bolton in press). Even though psychiatry, relative to other medical specialities, is more heavily involved in the psychosocial dimensions of the conditions of interest, the model of causation, risk, prevention, and treatment that applies in psychiatry, as it does across all of medicine, is biopsychosocial.

Classificatory Complexity

In the foregoing, the notion of the mind not working as it should was explicated in terms of the various faculties of mind. The issue, therefore, is that a particular faculty – belief, emotion, perception, reasoning, will – is not working as it should. These faculties are interrelated, and from its inception psychiatry sought to recognise patterns of symptoms and signs and to construct diagnostic categories on that basis. So a particular condition, say schizophrenia, comprises dysfunctions in multiple faculties of mind; e.g. paranoid delusions (belief), blunted affect (emotion), ambivalence (will), and auditory hallucinations (perception). It is now accepted that psychiatry’s classifications of its subject matter into discrete conditions is much more controversial than, say, ophthalmology’s classifications. Often this is expressed by saying that psychiatric categories lack validity, which in turn is often taken to mean that they do not “map onto any entity discernible in the real world” (Kinderman et al. 2013: 2). We can refer to this position as medical realism, the view that the validity of disease categories rests on the extent to which they “represent features of the underlying structure of the world” (Simon 2011: 66). In order to do so, the categories in question, typically, need to satisfy two conditions: (1) the category has to be separated from related categories by a “zone of rarity”; (2) the category has to be “associated with explanatory variables of deeper structural significance” such as “causal factors [and] pathogenetic mechanisms” (Jablensky 2016: 27; see also Kendell and Jablensky 2003). Accordingly, in light of a medical realist view, a valid disease entity is a ‘natural kind’.[2]

With a few notable exceptions such as the dementias and conditions such as Huntington’s Chorea, it is questionable whether current psychiatric categories can satisfy the two aforementioned requirements. Consider, first, the requirement for a zone of rarity surrounding the condition. In clinical medicine, a zone of rarity can be established on two grounds: clinical state and biomarkers. Clinical state refers to the symptoms and signs established during a clinical examination and by which the patient is determined to have a condition that is discontinuous with the ordinary functioning of the organ or system in question. For example, myocardial infarction is separated by a zone of rarity on the basis of clinical state: the experience of chest pain is qualitatively different from a healthy heart. On the other hand, a biomarker refers to a biological “characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention”.[3] In accordance with this definition, myocardial infarction is associated with a host of biomarkers such as Troponin and Creatine Kinase that, together with clinical state and other investigations, establish a zone of rarity surrounding the condition. Biomarkers can play  a key role in diagnosis, prognosis, and classification.

Moving on to psychiatry, there is now ample literature that casts doubt on the ability of current psychiatric classifications to establish a zone of rarity surrounding their putative conditions. In the philosophy of psychiatry literature, the assumption that psychiatric categories are natural kinds has long been questioned (e.g. Zachar 2015, 2000; Haslam 2002; cf. Cooper 2013). On the basis of clinical state, it has proven difficult to draw categorical distinctions between one disorder and another, and between disorder and its absence. Symptoms of schizophrenia and symptoms of bipolar disorder overlap, necessitating awkward constructions such as schizoaffective disorder or mania with psychotic symptoms. And the boundary between clinical depression and intense grief has been critiqued as indeterminate, with the distinction between the two made on the seemingly arbitrary specification of the number of weeks during which a person can feel low before a diagnosis is made (see Horwitz and Wakefield 2007).[4] And things are not better on the biomarker front; despite vigorous research, limited progress has been made in identifying biomarkers of clinical relevance, whether diagnostic, prognostic, or predictive (see Venkatasubramanian and Keshavan 2016; Kobeissy et al. 2013; Rose and Singh 2009). All of this indicates that there are difficulties in establishing a zone of rarity around key psychiatric categories.

Moving on to the second requirement identified earlier for a condition to constitute a natural kind – the requirement that the category is associated with distinctive aetiological and pathogenetic mechanisms – we find similar problems. Even though some progress has been made towards understanding the pathophysiology of schizophrenia, bipolar disorder, and depression, our understanding of the aetiology of these conditions remains at best provisional, with a multitude of non-specific factors interacting in complex ways over a long period of time. For example, research on molecular genetics – which has seen significant advancement in recent years with the use of whole-genome studies and large samples – has only been able to identify genetic commonalities that stretch across multiple psychiatric categories (see Jablensky 2016).

In summary, the majority of psychiatric conditions cannot properly meet the requirements for a medical realist view. Some critics of psychiatry take this conclusion to imply that psychiatric categories lack validity (e.g. Kinderman et al. 2013, Timimi 2014, all the way back to Szasz 1960). But all the critics can really assert is that current psychiatric categories do not meet the requirements for medical realism about disorder: they are not natural kinds. And that is not a problem for the identity of psychiatry as a medical speciality for three reasons: (1) Defenders of a medical realist view of psychiatric categories can simply point out that more work needs to be done to refine the existing categories and to improve the science and the research on biomarkers, aetiology, and pathogenesis.[5] (2) Alternatively, one could respond to the aforementioned critics by pointing out that there are many medical conditions that do not fully meet the requirements for medical realism yet are regarded as valid conditions that merit clinical attention and treatment. For example, the condition known as essential hypertension is not separated from normotension by a zone of rarity but is continuous with it, and neither is its causation entirely understood, hence its classification as ‘essential’ (or primary or idiopathic). Rheumatoid arthritis, while satisfying the zone of rarity requirement, is an autoimmune disorder whose aetiology is not understood. And some types of anaemia, while satisfying the aetiology requirement, are continuous with normal red blood cell size and number. (3) Finally, one could point out to the critics that medical realism is not the only option in medical ontology, another option being medical anti-realism.

Medical anti-realists reject the view that the diseases “we identify are either part of, or given to us by, the underlying structure of the world” (Simon 2011: 84). In contrast to medical realists, anti-realists do not accept the assumption of a mind-independent world that gives us our disease categories, rather such categories are pragmatic constructions driven by a range of criteria and stakeholders (see Simon 2011: 89-92).[6] Among the criteria that enter into recognising a set of symptoms and signs as a disease category are the ability of the category to give useful information on prognosis, to enable doctors to affect the course of the patient’s condition, to explain the patient’s prior condition, and to be therapeutically modifiable. Other criteria can be of a utilitarian and economic nature whereby disease categories are recognised if doing so would benefit society as a whole, or would be economically productive or viable. For example, the cut-off point for treating essential hypertension has to achieve a balance between expected treatment benefit (by reducing the risk of cardiovascular disease) and the economic considerations of offering this treatment in a national health system.

The aforementioned criteria are emphasised differently by the different stakeholders. Doctors, researchers, governments, pharmaceutical companies, and patient groups each have their own interests and varying abilities to influence the construction of disease categories. This creates the possibility for disagreement over the legitimacy of certain conditions, something we can see playing out in the ongoing debates surrounding Chronic Fatigue Syndrome, a condition that “receives much more attention from its sufferers and their supporters than from the medical community” (Simon 2011: 91). And, in psychiatry, it has long been noted that some major pharmaceutical companies influence the construction of disorder in order to create a market for the psychotropic drugs they manufacture. From the perspective of medical anti-realism (in the constructivist form presented here), these influences are no longer seen as a hindrance to the supposedly objective, ‘natural kind’ status of disease categories, but as key factors involved in their construction. Thus, the lobbying power of the American Psychiatric Association, the vested interests of pharmaceutical companies, and the desire of psychiatrists as a group to maintain their prestige do not undermine the identity of psychiatry as a medical specialty; what they do is highlight the importance of emphasising the interests of patient groups as well as utilitarian and economic criteria to counteract and respond to the other interests. Medical constructivism is not a uniquely psychiatric ontology, it is a medicine-wide ontology; it applies to schizophrenia as it does to hypertension, appendicitis, and heart disease. Owing to the normative complexity of psychiatry (outlined earlier) and to the fact that loss of freedom is often involved in psychiatric practice, the vested interests involved in psychiatry are more complex and harder to resolve than in many other medical specialties. But that in itself is not a hindrance to psychiatry’s identity as a medical speciality.

 *

We can see that on the normative, explanatory, and classificatory fronts, there is much that psychiatry can concede to its critics and still be able to able to maintain its identity as a medical speciality. It can concede the normative complexity of the psychiatric encounter while pointing out that this is a more challenging instance of the normative complexity of the general clinical encounter: values-based practice (alongside evidence-based practice) applies to all medical specialities. It can concede that it is more heavily invested in the psychosocial dimensions of the conditions of interest but that, like all medical specialities, it works within a biopsychosocial framework: the causality of all disorders is complex, across multiple levels. It can concede that a range of vested interests influences the construction of its disease categories, while pointing out that this is merely a more involved example of what occurs in all medical specialities.

References

Baker, M., and Menken, M. 2001. Time to Abandon the Term Mental Illness. BMJ 322: 937.

Biomarkers Definition Working Group. 2001. Biomarkers and Surrogate Endpoints: Preferred Definition and Conceptual Framework. Clinical Pharmacology and Therapeutics 69(3): 89-95.

Boorse, C. 2011. Concepts of Health and Disease. In Philosophy of Medicine (pp. ­13-64), F. Gifford (ed). Amsterdam: Elsevier.

Bolton, D. 2008. What is Mental Disorder? An Essay in Philosophy, Science and Values. Oxford: Oxford University Press.

Bolton, D. 2013a. What is Mental Illness. In The Oxford Handbook of Philosophy and Psychiatry (pp. 434-450), K.W.M. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds). Oxford: Oxford University Press.

Bolton, D. 2013b. Should Mental Disorder be Regarded as Brain Disorders? 21st Century Mental Health Sciences and Implications for Research and Training. World Psychiatry 12(1): 24-25.

Bolton, D. FORTHCOMING. The Biopsychosocial Model. Palgrave.

Bolton, D., and J. Hill. 2004. Mind, Meaning and Mental Disorder. Oxford: Oxford University Press.

Bolton, D., and N. Banner. 2012. Does Mental Disorder Involve Loss of Personal Autonomy? In Autonomy and Mental Disorder (pp. 77-99), L. Radoilska (ed.). Oxford: Oxford University Press.

Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G., Beuster, C., Bhunnoo, S., Browne, I., Chhina, N., Double, D., Downer, S., Evans, C., Fernando, S., Garland, M., Hopkins, W., Huw, R., Johnson, B., Martindale, B., Middleton, H., Moldavsky, D., Moncrieff, J., Mullins, S., Nelki, J., Pizzo, M., Rodger, J., Smyth, M., Summerfield, D., Wallace, J., and Yeomans, D. 2012. Psychiatry Beyond the Current Paradigm. British Journal of Psychiatry 201: 430-434.

Cooper, R. 2013. Natural Kinds. In The Oxford Handbook of Philosophy and Psychiatry (pp. 950-965), K.W.M. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds.). Oxford: Oxford University Press.

Fulford, K., van Staden, C. W., and Crisp, R. 2013. Values-based practice: Topsy-turvy take-home messages from ordinary language philosophy (and a few next steps). In The Oxford handbook of philosophy and psychiatry (pp. 385-412), K. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds.). Oxford: Oxford University Press.

Ghaemi, N. 2016. Utility without Validity is Useless. Current Opinion in Psychiatry 15(1): 35-37.

Haslam, N. 2002. Kinds of Kinds: A Conceptual Taxonomy of Psychiatric Categories. Philosophy, Psychiatry and Psychology 9, 203-217

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Horwitz, A., and Wakefield, J. 2007. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford: Oxford University Press.

Jablensky, A. 2016. Psychiatric Classifications: Validity and Utility. World Psychiatry 15(1): 26-31.

Kendell, R., and Jablensky, A. 2003. Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. American Journal of Psychiatry 160(1): 4-12. ­

Keil, G., Keuck, L., and Hauswald, R. 2017. Vagueness in Psychiatry: An Overview. In Vagueness in Psychiatry. G. Keil, L. Keuck, and R. Hauswald (eds.). Oxford: Oxford University Press.

Kinderman, P., Read, J., Moncrieff, J., and Bentall, R. 2013. Drop the Language of Disorder. Evidence Based Mental Health 16: 2-3.

Kingma, E. 2013. Naturalist Accounts of Mental Disorder. In The Oxford Handbook of Philosophy and Psychiatry (pp. 363-384), K.W.M. Fulford, M. Davies, R. Gipps, G. Graham, J. Sadler, G. Stanghellini, and T. Thornton (eds.). Oxford: Oxford University Press.

Kobeissy, F., Alawieh, A., Mondello, S., Boustany, R., and Gold, M. 2013. Biomarkers in Psychiatry: How Close Are We? Frontiers in Psychiatry 3(114): 1-2.

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Timimi, S. 2014. No More Psychiatric Labels: Why Formal Psychiatric Diagnostic Systems Should be Abolished. International Journal of Clinical and Health Psychology 14: 208-215.

Varga, S. 2015. Naturalism, Interpretation, and Mental Disorder. Oxford: Oxford University Press.

Venkatasubramanian, G., and Keshavan, M. 2016. Biomarkers in Psychiatry – A Critique. Annals of Neurosciences 23(1): 3-5.

White, P. D., Rickards, H., and Zeman, A. 2012. Time to End the Distinction Between Mental and Neurological Illnesses. BMJ 344: e3454.

Zachar, P. 2000. Psychiatric Disorders Are Not Natural Kinds. Philosophy, Psychiatry and Psychology 7: 167-182.

Zachar, P. 2015. Psychiatric Disorders: Natural Kinds Made by the World or Practical Kinds Made by Us? World Psychiatry 14(3), 288-290.

*

[1] Values-based practice is one such solution (see Fulford and Van Staden 2013).

[2] 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 is also 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).

[3] Biomarkers Definition Working Group (2001: 91).

[4] Indeterminacies of this kind have been discussed recently under the concept of ‘vagueness’; the notion that psychiatric 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). One possible implication of vagueness is a gradualist approach to mental health. For example, Sullivan-Bissett and colleagues (2017) argue that delusional and non-delusional beliefs differ in degree, not kind, a point that can also apply to the distinction between clinical depression and intense grief.

[5] An example of such attempts at refinement is the framework of the Research Domain Criteria (RDoC). See also Ghaemi (2016) and Bingham and Rashed (2014).

[6] As can be seen, the realist/anti-realist debate taps into fundamental issues in epistemology concerning our conception of truth. In the text I am not so much concerned with the status of that debate but simply with pointing out that there are alternatives to medical realism.

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.

 

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

mandess cover

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.