Mad Activism and Mental Health Practice

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

 

The Identity of Psychiatry in the Aftermath of Mad Activism

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

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THE IDENTITY OF PSYCHIATRY IN THE AFTERMATH OF MAD ACTIVISM

  1. INTRODUCTION

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

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

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

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

 

Madness & the Demand for Recognition

mandess cover

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

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

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

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

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

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

 

The Meaning of Madness

mandess cover

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

Islamic Perspectives on Psychiatric Ethics

My chapter published online at Oxford Handbooks.

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

Abstract

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

Click HERE for Pre-Production version

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.

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

(Discussion initiated by Patrick Allen)

Critical psychiatrists make – at least – four claims:

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

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

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

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

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

Click here for article

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

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

Abstract

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

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

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

Abstract for the 15th International Philosophy & Psychiatry Conference: July 2012: Autonomy and Agency in Islamic Culture & Theology: Implications for Psychiatric Ethics

 

Ethical practice in psychiatry is underpinned by a secular, anthropocentric concept of autonomy. While this reflects the cultural heritage of the communities where modern psychiatry was developed, it might not be suitable for populations with different understandings of autonomy. This presentation outlines some Islamic cultural/ethical issues of particular relevance to decision-making in psychiatry.

 

First, the scope of autonomy is considered. Outside one’s personal relation with God, autonomy is secondary to community. A collectivity can only achieve salvation when the conduct of each member is aligned with the norms of the faith. Moral/social violations are not individual choices but a threat to this order, and therefore of concern for others. Shared responsibility for the actions of others renders decision-making a collective enterprise guided by figures of authority. This has implications for informed consent, confidentiality, privacy, and the duty of clinicians towards patients.

 

Second, the paradox of agency is considered. Action in Islamic theology is both predetermined and the full responsibility of the agent. Suffering, in a determinist theodicy, is foreknown to God and is a trial and expiation for sins. This may promote fatalism towards treatment. With a free-will theodicy, humans bring suffering upon themselves through their actions, and must take an active attitude towards relieving it. Deterministic attitudes complicate the clinician’s duty to relieve suffering within the available means, and render sharing information (e.g. about prognosis) irrelevant. The presentation concludes by asking whether and to what extent a clinician should abandon her secular ethical principles in favour of other religious or cultural ones.

 

Intereseting blog on bioethics

Conference webpage

To Untie or Knot (and a change of opinion)

And this is what, now, seems to me an uncharacteristic ode to individualism. what had gone in to me at the time? I was probably too fed up with Mut; now I am not: in fact I am nostalgic. Which goes to show that intellectual positions can be emotionally laden too !

http://weekly.ahram.org.eg/2009/963/cu4.htm

To Judge or not to Judge: Confrontations with Rabt in the Dakhla Oasis

My destination was Mūt, the ‘urban’ centre of the Dakhla oasis. As I disembarked the ‘Upper Egypt Travel’ flea-ridden, cramped bus into the deserted streets of an August siesta, I was struck by the enormity of the mission that lay ahead: investigating Madness in the Western desert of Egypt, the practical part of my doctoral thesis. I wouldn’t say I wasn’t prepared; I had done my literature reviews, I had a good idea of the representations people employ to make sense of psychological and behavioural deviance, and I knew of the ubiquity of Jinn possession and magic, not only in the Western desert but all over Egypt. My initial fears of the impossibility of genuine access to the community turned out to be unfounded: within a few days I had already started my initiation in to the Dakhlan world-view. One thing I wasn’t prepared for was the extent my rational and moral sensibilities required stretching to accommodate what I was about to confront. It is one thing to understand why a people do what they do, but it’s quite another to take a moral stance towards their beliefs and practices. But here I was, wearing the Anthropologist’s hat, constantly reminding myself that I am here to understand and not to judge, yet frequently fighting the urge to throw it off and soothe my moral outrage.

It was at moments like this when I would reminisce on the tarnished history of anthropology. It is no secret that the systematic study of alien cultures started life as the intellectual arm of the late-imperialist enterprise. Back in those days (think late 19th, early 20th century) the world was simple and you were either civilised (meaning Euro-American) or not. Within the world-view prevalent at the time, the belief systems, practices, and more generally the way of life of the communities studied were judged against the intellectually, morally, and technologically advanced Europe and obviously found wanting, inferior. Magic was at best seen a symbolic practice, and at worst a form of proto-technology, a primitive attempt to control events in the world, something science is much, much better at. Outside anthropology, sentiments of superiority found expression in the myth of the Arian race and the Eugenics movement.

But things have changed: now a day it is common place for academics and thinkers to pride themselves in cultural relativism: “we live in different moral and cognitive worlds”, and to shy away from judgments based on a theory of linear progress. Relativism, it seems, became a moral imperative, a doctrine that no serious thinker or good man could risk writing off. An intended implication of relativism was to eliminate the possibility of hierarchical judgment, mainly by highlighting the coherence and meaningfulness of beliefs and practices when seen in the context of an overarching world-view. While it may seem obvious that sacrificial offerings to the gods of rain are an inferior method of begetting rain than modern rain-making technologies such as cloud seeding, the case remains that sacrificial practices cannot be assessed on the basis of a secular, technology-based world-view; this would completely miss the point of the practice, which in this case involves a confirmation and re-creation of the essential affinity of the individual with society and of both with a god imbued nature, precisely the stuff that a secular, technology-based world-view has eschewed.

So it was with an open-mind and a gentle-heart that I approached what I heard and saw. A week in to my stay in Mūt I made the acquaintance of a feisty thirty-four year old who practically accosted me off the coffee-shop near the old city. Old Mūt, by now mostly deserted, is a cornucopia of interlocking dwellings and shaded avenues built of mud-bricks on top of a low hill and was once completely surrounded by a wall with a gate that was locked at night. Some two decades ago the residents of the old city began to descend to the flatlands below and a surge of concrete and steel construction began that still shows no signs of abating. All over town you see one and two-floor buildings with concrete pillars sticking out of the roofs and bare steel rods dangling upwards, the whole construction eerily resembling a helpless upturned insect. But the beauty of Mūt is at its most magnificent just after sunrise, and just outside town, when the pastel coloured fields and the bordering sand dunes are bathed in golden light.

I spent many evenings with my feisty friend in the vicinity of the old city. He told me about the healers and magicians in town, introduced me to the local mad-men, shared with me insider-knowledge of the local prostitutes, and briefed me on the extent of Jinn possession. Naturally muscular and fairly handsome, he had tiny intelligent eyes that betrayed a degree of mischief, his whole demeanour and attitude seemingly non-conformist. Among all the people I later met he was the most critical of his brethren’s gullibility; their unwavering belief in magic and their tendency to invoke possession as an explanation for most ills. So it came as a surprise, several weeks later, when he told me that he has sought one of the local healers to help him with a domestic problem. For a week his wife had not been her usual self; she was pushing him away in bed, demanding to leave home, neglecting her duties, and displaying uncharacteristic episodes of anger and unexplainable tempers. This, he explained, is Rabt, and a healer must be sought to undo it. Up to this point my acquaintance with Rabt was seriously limited; I might have heard the term before, but it struck no chords. It was this phenomenon, however, that seriously challenged my relativistic tendencies.

Rabt is common all over Egypt, and particularly so in Dakhla. Literally ‘to be tied’, it is invoked to account for a range of problems from flaccid penises on wedding nights to marital discord and spinsterhood. Rabt is a form of magic, and therefore involves an envious or evil person taking the trouble to visit a magician with the goal of hurting or embarrassing some foe or nemesis. Like all magic, the harmful effects are mediated through a Jinni, or simply a direct consequence of the script embedded in the ‘Amal (think of it as an amulet that harms rather than protects). The Jinni may wreak havoc in a variety of ways: it may enter the body and settle inside the corpora of the penis preventing erection on the wedding night, it may aggravate the person’s Qarin (some sort of spirit double) resulting in bad tempers and mood swings (a.k.a marital discord), it may infatuate the person rendering them immune to human attraction and possibly leading to spinsterhood. In short Rabt works through a conglomerate of effects on its victims, ranging from the crudely physical to the psycho-emotional.

In my moral commitment to neutrality, I tried to understand Rabt in the context of the values and social constraints of this community. Isn’t Rabt an ingenious explanation for containing the painful irony of a flaccid penis on a wedding night that follows at least a decade of sexual expectation? Isn’t the externalisation of causation much more effective at protecting the married couple and their families from the disastrous possibility of male impotence, at least temporarily? And isn’t it much better to blame the evil actions of others for inter-relationship problems than to consider the actual relationship, its faults and merits, a consideration that may lead to divorce, an evil we must try to avoid? Yes, I thought to myself, Rabt makes sense, a lot of sense, if only we are charitable enough to see it within the wider context of a society trying to maintain the status co, to keep things as they are, and in the process to avoid facing the darker inevitabilities of life: some women and men will never marry, may not even want to marry, and some relationships just don’t work and must be brought to an end. Rabt then is a major device of mystification, side-stepping the working through that I am personally inclined to see as essential to managing relationships and life-situations in general. And herein lays the problem.

I can no longer keep on the Anthropologist’s hat; I have understood but that doesn’t seem to make me less inclined to judge. I have no trouble (or maybe some) stretching my rational sensibilities and accepting folk theories of spirits entering and exiting bodies and settling in penises, in fact I find them somewhat endearing. My problem is with a framework that functions to limit human potential, to nip change in the bud, and to subvert freedom by allowing no space for individual expression. This seems to me a powerful ideological onslaught targeting the individual. Its an onslaught that tries to deny my prerogative to express my wishes and desires, to be able to express my discontent at a lousy relationship through my tempers and moods, and not to have my mental states subverted of all possible referents, save for one that functions to keep me where I am: in a lousy relationship. Yet it is an onslaught maintained by each and every person who subscribes to it. My friend, who was not devoid of intelligence or critical tendencies, could not see in his wife’s revolt anything more than the doings of a malicious person. This is not to say he wasn’t aware their relationship was far from ideal. It was clear from our extended conversations that their personalities frequently clashed: him a strong-headed authoritarian, her a spoilt only-child who usually had it her way. But such is the power of subversive representations: they do not leave us with the truth, and instead appease our fears and serve collective rather than individual interests.

I still like my friend. I enjoy his energy and his impressive capacity at transforming a potentially boring coffee-shop in to a locus of contention, mainly by cheekily infuriating everyone and arguing over every little thing: without him the place would be far too serious. But I just can’t shake the thought that we are different, and fundamentally so. Whereas I carry through life privileging experience and change over social stasis, he is happy to fall back on constraining traditional representations when ever the potential for change shows itself. And while I can understand the power of society over the hapless individual, I cannot bring myself to regard this haplessness as absolute. I am therefore entitled to conceive an order of things, an order where Rabt is morally inferior.

To judge is to be human, and it is a myth of academic anthropological discourse that we must eschew judgement from our interpretive, descriptive account of how things are. To be sure we need to understand before we hasten to make judgments, but in the absence of a moral and rational ordering of things, the whole research endeavour will suffer from a sterility that renders it merely a topic of scholarly debate, with little relevance to the important, constructive vision of how the confrontation of world-views can lead to a critical assessment of both.

Mohammed Abouelleil Rashed 2009