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 But these debates are themselves superseded by a foundational challenge to psychiatry’s identity as a medical speciality, a challenge that emanates from particular approaches in mental health activism.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.

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.

A History of Mental Health Advocacy & Activism (Beginnings to 1990s)

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  1. Early advocacy and activism

The modern consumer/service-user/survivor movement is generally considered to have begun in the 1970s in the wake of the many civil rights movements that emerged at the time.[1] The Survivors’ History Group – a group founded in April 2005 and concerned with documenting the history of the movement – traces an earlier starting point.[2] The group sees affinity between contemporary activism and earlier attempts to fight stigma, discrimination and the poor treatment of individuals variously considered to be mad, insane and, since the dominance of the medical idiom, to suffer with mental illness.[3] In their website which documents Survivor history, the timeline begins with 1373, the year the Christian mystic Margery Kempe was born. Throughout her life, Margery experienced intense voices and visions of prophets, devils, and demons. Her unorthodox behaviour and beliefs upset the Church, the public, her husband, and resulted in her restraint and imprisonment on a number of occasions. Margery wrote about her life in a book in which she recounted her spiritual experiences and the difficulties she had faced.[4]

The Survivors’ history website continues with several recorded instances of individual mis-treatment on the grounds of insanity. But the first explicit evidence of collective action and advocacy in the UK appears in 1845 in the form of the Alleged Lunatics’ Friend Society: an organisation composed of individuals most of whom had been incarcerated in madhouses and subjected to degrading treatment (Hervey 1986). For around twenty years, the Society campaigned for the rights of patients, including the right to be involved in decisions pertaining to their care and confinement. In the US, around the same time, patients committed to a New York Lunatic Asylum produced a literary magazine – The Opal – published in ten volumes between 1851 and 1860. Although this production is now seen to have painted a rather benign picture of asylum life, and to have allowed voice only to those patients who were deemed appropriate and self-censorial (Reiss 2004), glimpses of dissatisfaction and even of liberatory rhetoric emerge from some of the writing (Tenney 2006).

An important name in what can be considered early activism and advocacy is Elizabeth Packard. In 1860, Packard was committed to an insane asylum in Illinois by her husband, a strict Calvinist who could not tolerate Packard’s newly expressed liberal beliefs and her rejection of his religious views. At the time, state law gave husbands this power without the need for a public hearing. Upon her release, Packard campaigned successfully for a change in the law henceforth requiring a jury trial for decisions to commit an individual to an asylum (Dain 1989, p.9). Another important campaigner is Clifford Beers, an American ex-patient who published in 1908 his autobiography A Mind That Found Itself. Beer’s biography documented the mistreatment he experienced at a number of institutions. The following year he founded the National Committee for Mental Hygiene (NCMH), an organisation that sought to improve conditions in asylums and the treatment of patients by working with reform-minded psychiatrists. The NCMH achieved limited success in this respect, and its subsequent efforts focused on mental health education, training, and public awareness campaigns in accordance with the then dominant concept of mental hygiene (Dain 1989, p. 6).

  1. 1900s−1950s: ‘Mental Hygiene’

On both sides of the Atlantic, mental health advocacy in the first few decades of the 20th century promoted a mental hygiene agenda.[5] Mental hygiene is an American concept and was understood as “the art of preserving the mind against all incidents and influences calculated to deteriorate its qualities, impair its energies, or derange its movements” (Rossi 1962). These “incidents and influences” were conceived broadly and included “exercise, rest, food, clothing and climate, the laws of breeding, the government of the passions, the sympathy with current emotions and opinions, the discipline of the intellect”, all of which had to be governed adequately to promote a healthy mind (ibid.). With such a broad list of human affairs under their purview, the mental hygienists had to fall back on a set of values by which the ‘healthy’ life-style was to be determined. These values, as argued by Davis (1938) and more recently by Crossley (2006), were those of the educated middle classes who promoted mental hygiene in accordance with a deeply ingrained ethic. For example, extra-marital sex was seen as a deviation and therefore a potential source of mental illness. Despite this conservative element, the discourse of mental hygiene was progressive, for its time, in a number of ways: first, it considered mental illness to arise from interactions among many factors, including the biological and the social, and hence to be responsive to improvements in the person’s environment; second, it fought stigma by arguing that mental illness is similar to physical illness and can be treated; third, it promoted the prevention of mental illness, in particular through paying attention to childhood development; and fourth, it argued for the importance of early detection and treatment (Crossley 2006, pp. 71-75).

In the US, Clifford Beer’s own group, the NCMH, continued to advance a mental hygiene agenda and, in 1950, merged with two other groups to form the National Association for Mental Health, a non-profit organisation that exists since 2006 as Mental Health America.[6] In the UK, mental hygiene was promoted by three inter-war groups that campaigned for patient wellbeing and education of the public. These groups merged, in 1946, to form the National Association for Mental Health (NAMH), which later, in 1972, changed its name to Mind, the name under which it remains to this day as a well-known and influential charity.[7] In the late 50s, these two groups continued to educate the public through various campaigns and publications, and were involved in training mental health professionals in accordance with hygienist principles. In addition, they were advocates for mental patients, campaigning for the government to improve commitment laws, and, in the UK, working with the government to instate the move from asylums to ‘care in the community’.

Even though the discourse of mental hygiene was dominant during these decades, the developments that were to come in the early 70s were already taking shape in the emerging discourse of civil rights. A good example of these developments in the UK is the National Council for Civil Liberties (NCCL), better known today as Liberty. Founded in 1934 in response to an aggressive police reaction to protestors during the “hunger marches”, it became involved in 1947 in its first “mental health case”: a woman wrongly detained in a mental health institution for what appeared to be ‘moral’ rather than ‘medical’ reasons.[8] During the 50s, the NCCL campaigned vigorously for reform of mental health law to address this issue, and was able to see some positive developments in 1959 with the abolition of the problematic 1913 Mental Deficiency Act and the introduction of tribunals in which patients’ interests were represented.

  1. 1960s: The ‘Anti-psychiatrists’

During the 1960s criticism of mental health practices and theories was carried through by a number of psychiatrists who came to be referred to as the ‘anti-psychiatrists’. Most famous among them were Thomas Szasz, R. D. Laing, and David Cooper. Szasz (1960) famously argued that mental illness is a myth that legitimizes state oppression (via the psychiatric enterprise) on those judged as socially deviant and perceived to be a danger to themselves or others. Mental illnesses for Szasz are problems in living: morally and existentially significant problems relating to social interaction and to finding meaning and purpose in life. Laing (1965, 1967) considered the medical concept of schizophrenia to be a label applied to those whose behaviour seems incomprehensible, thereby permitting exercises of power. For Laing (1967, p. 106) the people so labelled are not so much experiencing a breakdown but a breakthrough: a state of ego-loss that permits a wider range of experiences and may culminate in a “new-ego” and an “existential rebirth”. These individuals require guidance and encouragement, and not the application of a psychiatric label that distorts and arrests this process. David Cooper (1967, 1978) considered ‘schizophrenia’ a revolt against alienating familial and social structures with the hope of finding a less-alienating, autonomous yet recognised existence. In Cooper’s (1978, p. 156) view, it is precisely this revolt that the ‘medical apparatus’, as an agent of the ‘State’, aims to suppress.

From the perspective of those individuals who have experienced psychiatric treatment and mental distress, the anti-psychiatrists of the 1960s were not activists but dissident mental health professionals. As will be noted in the following section, the mental patients’ liberation movement did not support the inclusion  of sympathetic professionals within its ambit. Nevertheless, the ideas of Thomas Szasz, R. D. Laing, and David Cooper were frequently used by activists themselves to ground their critique of mental health institutions and the medical model. At the time, these ideas were radical if not revolutionary, and it is not surprising that they inspired activists engaged in civil rights struggles in the 1970s.

  1. The 1970s civil rights movements

Civil rights activism in mental health began through the work of a number of groups that came together in the late 60s and early 70s in the wake of the emerging successes and struggles of Black, Gay and women civil rights activists. In the UK, a notable group was the Mental Patients’ Union (1972), and in the US three groups were among the earliest organisers: Insane Liberation Front (1970), Mental Patients’ Liberation Front (1971), and Network Against Psychiatric Assault (1972).[9] An important difference between these groups and earlier ones that may have also pursued a civil rights agenda such as the NCCL, is that they, from the start or early on, excluded sympathetic mental-health professionals and were composed solely of patients and ex-patients. Judi Chamberlin (1990, p. 324), a key figure in the American movement, justified it in this way:

Among the major organising principles of [black, gay, women’s liberation movements] were self-definition and self-determination. Black people felt that white people could not truly understand their experiences … To mental patients who began to organise, these principles seemed equally valid. Their own perceptions about “mental illness” were diametrically opposed to those of the general public, and even more so to those of mental health professionals. It seemed sensible, therefore, not to let non-patients into ex-patient organisations or to permit them to dictate an organisation’s goals.

The extent of the resolve to exclude professionals – even those who would appear to be sympathetic such as the anti-psychiatrists – is evident in the writings of Chamberlin as well as in the founding document of the Mental Patients’ Union. Both distance themselves from anti-psychiatry on the grounds that the latter is “an intellectual exercise of academics and dissident mental health professionals” which, while critical of psychiatry, did not include ex-patients or engage their struggles (Chamberlin 1990, p. 323).[10] Further, according to Chamberlin, a group that permits non-patients and professionals inevitably abandons its liberatory intentions and ends up in the weaker position of attempting to reform psychiatry. And reform was not on the agenda of these early groups.

On the advocacy front, the mental patients’ liberation movement – the term generally used to refer to this period of civil rights activism – sought to end psychiatry as they knew it.[11] They sought to abolish involuntary hospitalisation and forced treatment, to prioritise freedom of choice and consent above other considerations, to reject the reductive medical model, to restore full civil rights to mental patients including the right to refuse treatment, and to counter negative perceptions in the media such as the inherent dangerousness of the ‘mentally ill’. In addition to advocacy, a great deal of work went into setting up non-hierarchical, non-coercive alternatives to mental health institutions such as self-help groups, drop-in centres, and retreats.[12] The purpose of these initiatives was not only to provide support to individuals in distress, but to establish that mental patients are self-reliant and able to manage their own lives outside of mental health institutions. Central to the success of these initiatives was a radical transformation in how ex-patients understood their situation. This transformation was referred to as consciousness-raising.

Borrowed from the women’s liberation movement, consciousness-raising is the process of placing elements of one’s situation in the wider context of systematic social oppression (Chamberlin 1990). This begins to occur in meetings in which people get together and share their experiences, identifying commonalities, and re-interpreting them in a way that gives them broader meaning and significance. An implication of this process is that participants may be able to reverse an internalised sense of weakness or incapability – which hitherto they may have regarded as natural – and regain confidence in their abilities. In the mental patients’ liberation movement, consciousness-raising involved ridding oneself of the central assumptions of the ‘mental health system’: that one has an illness, and that the medical profession is there to provide a cure. In the discourse of the time, inspired by the writings of Thomas Szasz and others, psychiatry was a form of social control, medicalising unwanted behaviour as a pre-text for ‘treating’ it and forcing individuals into a sane way of behaving. By sharing experiences, participants begin to see that the mental health system has not helped them. In a book first published in 1977 and considered a founding and inspirational document for mental health activists, Chamberlin (1988, pp. 70-71) writes of the important insights ex-patients gained through consciousness-raising:

Consciousness-raising … helps people to see that their so called symptoms are indications of real problems. The anger, which has been destructively turned inward, is freed by this recognition. Instead of believing that they have a defect in their psychic makeup (or their neurochemical system), participants learn to recognise the oppressive conditions in their daily lives.

Mental suffering and distress, within this view, are a normal response to the difficulties individuals face in life such as relationship problems, social inequality, poverty, loss and trauma. In such situations, individuals need a sympathetic, caring and understanding response, and not the one society offers in the form of psychotropic drugs and the difficult environment of a mental health hospital (Chamberlin 1988).  Consciousness-raising does not stop at the ‘mental health system’, and casts a wider net that includes all discriminatory stereotypes against ex-patients. In a deliberate analogy with racism and sexism, Chamberlin uses the term mentalism to refer to the widespread social tendency to call disapproved of behaviour ‘sick’ or ‘crazy’. Mental patients’ liberation required of patients and ex-patients to resist the ‘mental health system’ as well as social stereotyping, and to find the strength and confidence to do so. In this context, voluntary alternatives by and for patients and ex-patients were essential to providing a forum for support and consciousness-raising.

  1. Consumers/Service-Users & Survivors

In the 1980s, the voices of advocates and activists began to be recognised by national government agencies and bodies. This was in the context of a shift towards market approaches to health-care provision, and the idea of the patient as a consumer of services (Campbell 2009). Patients and ex-patients – now referred to as consumers (US) or users (UK) of services – were able to sit in policy meetings and advisory committees of mental health services and make their views known. Self-help groups, which normally struggled for funding, began to be supported by public money. In the US, a number of consumer groups formed that were no longer opposed to the medical model or to working with mental health professionals in order to reform services.[13] While some considered these developments to be positive, others regarded them as indicating what Linda Morrison, an American activist and academic, referred to as a “crisis of co-optation”: the voice of mental health activists had to become acceptable to funding agencies, which required relinquishing radical demands in favour of reform (Morrison 2005, p. 80). Some activists rejected the term consumer as it implied that patients and professionals were in an equal relation, with patients free to determine the services they receive (Chamberlin 1988, p. vii).[14]

Countering the consumer/user discourse was an emerging survivor discourse reflected in a number of national groups, for example the National Association of Psychiatric Survivors (1985) in the US and Survivors Speak Out (1986) in the UK. Survivor discourse shared many points of alignment with earlier activism, but whereas the latter was opposed to including professionals and non-patients, survivors were no longer against this as long as it occurred within a framework of genuine and honest partnership and inclusion in all aspects of service structure, delivery and evaluation (Chamberlin 1995, Campbell 1992). [15]

In the US, developments throughout the 1990s and into the millennium confirm the continuation of these two trends: the first oriented towards consumer discourse and involvement, and the second towards survivors, with a relatively more radical tone and a concern with human rights (Morrison 2005). Today, representative national groups for these two trends include, respectively, the National Coalition for Mental Health Recovery (NCMHR), and Mind Freedom International (MFI).[16] The former is focused on promoting comprehensive recovery, approvingly quoting the ‘New Freedom Mental Health Commission Report’ target of a “future when everyone with mental illness will recover”.[17] To this end they campaign for better services, for consumers to have a voice in their recovery, for tackling stigma, discrimination, and promoting community inclusion via consumer-run initiatives that offer assistance with education, housing and other aspects of life. On the other hand, MFI state their vision to be a “nonviolent revolution in mental health care”. Unlike NCMHR, MFI do not use the language of ‘mental illness’, and support campaigns such as Creative Maladjustment, Mad Pride, and Boycott Normal. Further, MFI state emphatically that they are completely independent and do not receive funds from or have any links with government, drug companies or mental health agencies.[18] Despite their differences, both organisations claim to represent both survivors and consumers, and both trace their beginnings to the 1970s civil rights movements. But whereas NCMHR refer to ‘consumers’ always first and generally more often, MFI do the opposite and state that the majority of their members identify as psychiatric survivors.

In the UK, the service-user/survivor movement – as it came to be referred to – is today represented nationally by a number of groups.[19] Of note is the National Survivor User Network (NSUN) which brings together survivor and user groups and individuals across the UK in order to strengthen their voice and assist with policy change.[20] Another long-standing group (1990), though less active today, is the UK Advocacy Network, a group which campaigns for user led advocacy and involvement in mental health services planning and delivery.[21] A UK survey done in 2003 brings some complexity to this appearance of a homogenous movement (Wallcraft et al. 2003). While most respondents agreed that there is a national user/survivor movement – albeit a rather loose one – different opinions arose on all the important issues; for example, disagreements over whether compulsory treatment can ever be justified, and whether receiving funds from drug companies compromises the movement. In addition, there were debates over the legitimacy of the medical model, with some respondents rejecting it in favour of social and political understandings of mental distress. In this context, they drew a distinction between the service-user movement and the survivor movement, the former concerned with improving services, and the latter with challenging the medical model and the “supposed scientific basis of mental health services” (Wallcraft et al. 2003, p. 50). More radical voices suggested that activists who continued to adopt the medical model have not been able to rid themselves of the disempowering frameworks of understanding imposed by the mental health system. In a similar vein, some respondents noted the de-politicisation of the movement, as activists ceased to be primarily concerned with civil rights and began to work for the mental health system (Wallcraft et al. 2003, p. 14).

In summary, there exists within the consumer/service-user/survivor movements in the US and the UK a variety of stances in relation to involuntary detention and treatment, acceptable sources of funding, the medical model, and the extent and desirability of user involvement in services. Positions range from working for mental health institutions and reforming them from the ‘inside’, to rejecting any co-operation and engaging in activism to end what is considered psychiatric abuse and social discrimination in the guise of supposed medical theory and treatment. It appears that within national networks and movements pragmatic and co-operative approaches are more common, with radical positions pushed somewhat aside though by no means silenced. In this context Mad Pride, representing the latest wave of activism in mental health, re-invigorates the radicalism of the movement and makes the most serious demand yet of social norms and understandings. But Mad Pride, underpinned by the notions of Mad culture and Mad identity, builds on the accomplishments of Survivor identity to which I now briefly turn.

  1. Survivor identity

The connotations of survivor discourse are unmistakable and powerful. With survivor discourse the term ‘patient’ and its implications of dependence and weakness are finally discarded (Crossley 2004, p.169). From the perspective of those individuals who embraced the discourse, there is much that they have survived: forced detention in the mental health system; aggressive and unhelpful treatments; discrimination and stigma in society; and, for some, the distress and suffering they experienced and which was labelled by others ‘mental illness’. By discarding of what they came to see as an imposed identity – viz. ‘patient’ – survivors took one further step towards increased self-definition (Crossley 2006, p. 182). Further, the very term ‘survivor’ implies a positive angle to this definition in so far as to survive something implies resilience, strength, and other personal traits considered valuable. Morrison (2005, p. 102) describes it as the “heroic survivor narrative” and accords it a central function in the creation of a collective identity for the movement and a shared sense of injustice.

Central to survivor identity is the importance of the voice of survivors, and their ability to tell their own stories, a voice which neither society nor the psychiatric system respected. The well-known British activist and poet Peter Campbell (1992, p. 122) writes that a great part of the “damage” sustained in the psychiatric system

has been a result of psychiatry’s refusal to give value to my personal perceptions and experience … I cannot believe it is possible to dismiss as meaningless people’s most vivid and challenging interior experiences and expect no harm to ensue.

The emphasis on survivor voice highlights one further difference from 1970s activism: whereas earlier activists sustained their critique of psychiatry by drawing upon the writings of Szasz, Goffman, Marx and others, survivor discourse eschewed such sources of ‘authority’ in favour of the voice of survivors themselves; Crossley (2004, p. 167) writes:

Survivors have been able to convert their experiences of mental distress and (mis)treatment into a form of cultural and symbolic capital. The disvalued status of the patient is reversed within the movement context. Therein it constitutes authority to speak and vouches for authenticity. The experience of both distress and treatment, stigmatized elsewhere, has become recognized as a valuable, perhaps superior knowledge base. Survivors have laid a claim, recognized at least within the movement itself, to know ‘madness’ and its ‘treatment’ with authority, on the basis that they have been there and have survived it.

Survivors are therefore experts on their own experiences, and experts on what it is like to be subject to treatment in mental health institutions and to face stigma and discrimination in society. So construed, to survive is to be able to emerge from a range of difficulties, some of which are external and others internal, belonging to the condition (the distress, the experiences) that led to the encounter with psychiatry in the first place. In this sense, survivor discourse had not yet been able to impose a full reversal of the negative value attached to phenomena of madness, a value reflected in the language of mental illness, disorder and pathology. This is clearly evident in the idea that one had survived the condition, for if that is the attitude one holds towards it, it is unlikely that the ‘condition’ is looked upon positively or neutrally (except perhaps teleologically in the sense that it had had a formative influence on one’s personality). Similarly, if one considers oneself to have survived mental health institutions rather than the condition, there still is no direct implication that the condition itself is regarded in a non-negative light, only that the personal traits conducive to survival are laudable. It is only with the discourse of Mad Pride, yet to come, that the language of mental illness and the social norms and values underpinning it are challenged in an unambiguous manner.

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] The following account outlines key moments, figures, groups and strategies in mental health advocacy and activism; it is not intended to be exhaustive but rather to illustrate the background to the Mad Pride movement and discourse.

[2] The timeline can be found at: http://studymore.org.uk/mpu.htm. (The website states that Survivor history is being compiled into a book.) See also Campbell and Roberts (2009).

[3] In contrast to Survivor history, there is a tradition of historical and critical writing on the history of ‘psychiatry’ and ‘madness’, and on the development of lunacy reform and mental health law. Notable names in this tradition are Roy Porter, Andrew Scull, and Michel Foucault.

[4] See Peterson (1982, pp. 3-18).

[5] This section benefits, in part, from Crossley’s (2006, Chapter 4) account of mental hygiene.

[6] Mental Health America. Online: http://www.mentalhealthamerica.net/

[7] Mind. Online: http://www.mind.org.uk/

[8] The history of Liberty can be found on their website: https://www.liberty-human-rights.org.uk/who-we-are/history/liberty-timeline

[9] In the US, groups were able to communicate with each other through a regular newsletter, Madness Network News (1972-1986), and an annual Conference on Human Rights and Against Psychiatric Oppression (1973-1985).

[10] For a similar point see the founding document of the Mental Patients’ Union, reprinted in Curtis et al. (2000, pp. 23-28).

[11] Some activists referred to themselves as ‘psychiatric inmates’ or ‘ex-inmates’ highlighting the fact of their incarceration in mental institutions and their rejection of the connotations of the term ‘patient’. This early difference in terminology – inmate versus patient – prefigures the multiplicity of terms and associated strategies that will come to define activism and advocacy in mental health to this day.

[12] The earliest example of a self-help group is WANA (We Are Not Alone). Formed in New York in the 1940s as a patient-run group, it developed into a major psychosocial rehabilitation centre, eventually to be managed by mental health professionals (see Chamberlin 1988, pp. 94-95).

[13] See Bluebird’s History of the Consumer/Survivor Movement. Online: https://www.power2u.org/downloads/HistoryOfTheConsumerMovement.pdf

[14] Mclean (1995, p. 1054) draws the distinction between consumers and survivors as follows: “Persons who identify themselves as ‘consumers’, ‘clients’ or ‘patients’, tend to accept the medical model of mental illness and traditional mental health treatment practices, but work for general system improvement and for the addition of consumer controlled alternatives. Those who refer to themselves as ‘ex-patients’, ‘survivors’ or ‘ex-inmates’ reject the medical model of mental illness, professional control and forced treatment and seek alternatives exclusively in user controlled centres.”

[15] Consumers and survivors aside, more radical voices persisted, continuing the discourse and activities of the 1970s’ groups. These voices were vehemently opposed to psychiatry and rejected any cooperation with services or with advocates/activists who tended towards reform. Examples include the Network to Abolish Psychiatry (1986) in the US and Campaign Against Psychiatric Oppression (CAPO, 1985) in the UK, both of which were active for a few years in the 1980s. (CAPO was an offshoot of the earlier Mental Patients’ Union.) For these groups, the ‘mental health system’ was intrinsically oppressive and had to be abolished: attempts to reform it, merely strengthened it (see Madness Network News, Summer 1986, vol.8, no.3, p.8). Reflecting on the beginnings of Survivors Speak Out (SSO, 1986), Peter Campbell, a founder, wrote that CAPO and other “separatist” groups were more concerned with “philosophical and ideological issues” and that SSO was “born partly in reaction to this: they were the first part of the ‘pragmatic’ wing which now dominates the user movement” with an emphasis on dialogue with others (Peter Campbell on The History and Philosophy of The Survivor Movement. Southwark Mind Newsletter, issue 24 – year not specified).

[16] Note that the reference here is to national networks and groups and not the local groups engaged in self-help, support, education, training, and advocacy of which there are hundreds in the US, UK and elsewhere.

[17] National Coalition for Mental Health Recovery. Online: http://www.ncmhr.org/purpose.htm

[18] Mind Freedom International. Online: http://www.mindfreedom.org/mfi-faq

[19] National organisations are of two types: those concerned with mental health generally (discussed in the text), and those with a focus on a particular condition or behaviour such as the Hearing Voices Network and the National Self-Harm network.

[20] National Survivor User Network. Online: https://www.nsun.org.uk/our-vision

[21] UK Advocacy Network. Online: http://www.u-kan.co.uk/mission.html

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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

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.

 

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

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

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.