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 But these debates are themselves superseded by a foundational challenge to psychiatry’s identity as a medical speciality, a challenge that emanates from particular approaches in mental health activism.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

Best of 2018 Philosophy List by Oxford University Press

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

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

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

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

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

  1. WHAT IS CULTURE?

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

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

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

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

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

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

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

2. CAN MADNESS CONSTITUTE A CULTURE? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Mohammed Abouelleil Rashed (2018)

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

***

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

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

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

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

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

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

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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.

 

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.