Check out Oxford University Press’ list of articles chosen from across its journals to represent the ‘Best of 2018’.
For other articles, I enjoyed reading Roger Scruton’s Why Beauty Matters in The Monist.
Check out Oxford University Press’ list of articles chosen from across its journals to represent the ‘Best of 2018’.
For other articles, I enjoyed reading Roger Scruton’s Why Beauty Matters in The Monist.
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):
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.
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”. 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”. 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. 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. 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). 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).
 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”.
 Sanism: discrimination and prejudice against people perceived to have, or labelled as having, a mental disorder. The equivalent term in disability activism is ableism.
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. The Survivors’ History Group – a group founded in April 2005 and concerned with documenting the history of the movement – traces an earlier starting point. 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. 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.
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).
On both sides of the Atlantic, mental health advocacy in the first few decades of the 20th century promoted a mental hygiene agenda. 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. 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. 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. 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.
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.
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). 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). 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. 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. 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.
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. 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).
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). 
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). 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”. 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. 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. 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. 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. 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.
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).
 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.
 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.
 See Peterson (1982, pp. 3-18).
 This section benefits, in part, from Crossley’s (2006, Chapter 4) account of mental hygiene.
 The history of Liberty can be found on their website: https://www.liberty-human-rights.org.uk/who-we-are/history/liberty-timeline
 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).
 For a similar point see the founding document of the Mental Patients’ Union, reprinted in Curtis et al. (2000, pp. 23-28).
 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.
 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).
 See Bluebird’s History of the Consumer/Survivor Movement. Online: https://www.power2u.org/downloads/HistoryOfTheConsumerMovement.pdf
 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.”
 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).
 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.
 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.
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 article HERE.
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
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.
(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). 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…
[Excerpt from Chapter 4 of my book Madness & the Demand for Recognition, forthcoming Oxford University Press, 2018]
In the foregoing account of identity (section 4.2) there is frequent mention of the demand for recognition (indeed, the title of the book features the same). We have made some progress towards understanding the nature of the gaps in social validation under which such a demand can become possible: individuals who are unable to find their self-understanding reflected in the social categories with which they identify and who are demanding social change to address this; what motivates people to seek this kind of social change – what motivates them to struggle for recognition?
4.3 THE STRUGGLE FOR RECOGNITION
4.3.1 The motivation for recognition
There are, at least, four possible sources of motivation for recognition. One of these sources has already been identified in the discussion of Hegel’s teleology (section 3.5.1). In accordance with this, the struggle for more equal and mutual forms of recognitive relations is driven forward by the telos of human nature which is the actualisation of freedom: if that is the ultimate goal, then the dialectical development of consciousness’ understanding of itself will lead to an awareness of mutual dependency as a condition of freedom. But this account has been considered and rejected on the grounds that positing an ultimate, rational telos for human beings that tends towards realisation is a problematic assumption, with connotations to the kind of metaphysical theorising which Kant’s critical philosophy had put to rest. The metaphysical source of the motivation for recognition must be rejected.
Another possible source is empirical and has to do with the psychological nature of human beings. In the Struggle for Recognition, Axel Honneth (1996) provides such an account through the empirical social psychology of G. H. Mead. According to Mead (1967) the self develops out of the interaction of two perspectives: the ‘me’ which is the internalised perspective of the social norms of the generalised other, and the ‘I’ which is a response to the ‘me’ and the source of individual creativity and rebellion against social norms. It is the movement of the ‘I’ – the impulse to individuation – that shows up the limitations of social norms and motivates the expansion of relations of recognition (see Honneth 1996, pp. 75-85).
In a later work Honneth (2002, p. 502) rejects his earlier account; he begins by noting: “there has always seemed to me to be something particularly attractive about the idea of an ongoing struggle for recognition, though I did not quite see how it could still be justified today without the idealistic presupposition of a forward-driven process of Spirit’s complete realization”. Honneth thus rejects the teleological account that we, also, found wanting. He then goes on to render problematic his earlier proposal that seeks to ground the motivation for recognition in Mead’s social psychology:
I have come to doubt whether [Mead’s] views can actually be understood as contributions to a theory of recognition: in essence, what Mead calls ‘recognition’ reduces to the act of reciprocal perspective taking, without the character of the other’s action being of any crucial significance; the psychological mechanism by which shared meanings and norms emerge seems to Mead generally to develop independently of the reactive behaviour of the two participants, so that it also becomes impossible to distinguish actions according to their respective normative character. (Honneth 2002, p. 502)
In other words, what Mead describes is a general process that is always occurring behind people’s backs in so far as it is a basic feature of the human life form. His theory explains how shared norms emerge and why they expand but deprives agents’ behaviours towards each other of normative significance. They become unwitting subjects of this process rather than agents struggling for recognition. To struggle for recognition is to perceive oneself to be denied a status one is worthy of, and not to mechanically act out one’s innate nature. And this remains the case even if our treatment by others engenders feelings of humiliation and disrespect. To experience humiliation is to already consider oneself deserving of a certain kind of treatment, of a normative status that is denied. Such feelings, therefore, cannot themselves constitute the motivation for recognition, rather they are symptoms of the prior existence of a conviction that one must be treated in a better way.
If the motivation for recognition cannot be accounted for metaphysically (by the teleology of social existence), or empirically (by the facts of one’s psychological nature), or emotionally (by the powerful feelings that signal the need for social change), then it must somehow be explained with reference to the ideas that together make up the theory of recognition. These ideas include specific understandings of individuality, self-realisation, freedom, authenticity, social dependence, the need for social confirmation, in addition to notions of dignity, esteem, and distinction, among others. To be motivated to struggle for recognition is to already be shaped by a historical tradition where such notions have become part of how we relate to ourselves and others, and the normative expectations that structure such relations; as McBride (2013, p. 137) writes, “we are the inheritors of a long and complex history of ethical, religious, philosophical, and, more recently, social scientific thought about the stuff of recognition: pride, honour, dignity, respect, status, distinction, prestige”. It is partly that we are within the space of these notions that we can see, as pointed out in section 3.5.2, that living a life of delusion and disregard for what others think, or a life of total absorption in social norms, is not to live a worthwhile life, for we would be giving up altogether either on social confirmation or on our individuality. We are motivated by these notions in so far as we are already constituted socially so as to be moved by them.
Putting the issue this way may raise concerns. By grounding the motivation for recognition in the subject’s prior socialisation, it becomes harder to establish whether that motivation is, ultimately, a means for the individual to broaden his or her social freedom, or a means for reproducing existing relations of domination. As McNay (2008, p. 10) writes, “the desire for recognition might be far from a spontaneous and innate phenomenon but the effect of a certain ideological manipulation of individuals” (see also McBride 2013, pp. 37-40; Markell 2003). Honneth (2012, p. 77) provides a number of examples where recognition may be seen as contributing to the domination of individuals:
The pride that ‘Uncle Tom’ feels as a reaction to the constant praises of his submissive virtues makes him into a compliant servant in a slave-owning society. The emotional appeals to the ‘good’ mother and housewife made by churches, parliaments or the mass media over the centuries caused women to remain trapped within a self-image that most effectively accommodated gender-specific division of labour.
Instead of constituting moral progress (in the sense of an expansion of individual freedom), recognition becomes a mechanism by which people endorse the very identities that limit their freedom. They seek recognition for these identities and in this way “voluntarily take on tasks or duties that serve society” (Honneth 2012, p. 75). There is a need, therefore, to see if we can distinguish ideological forms of recognition from those relations of recognition in which genuine moral progress can be said to have occurred, since what we are after are relations of the latter sort.
4.3.2 The problem of ideology
I first consider, and exclude, some ways in which the problem of ideology cannot be solved. It may seem attractive to find a solution by appeal to a Kantian notion of rational autonomy, where the subject withdraws from social life in order to know what it ought to do. If such withdrawal were possible, we would have had an instance of genuine recognition in the sense that an autonomous choice has been made. But as argued in section 3.2, withdrawing to pure reason can only produce the form that moral principles must take, without those principles thereby possessing sufficient content that can guide action. Moral principles acquire content, and hence can be action guiding, through the very social practices that Kant urged us to withdraw from in order to exercise our rational autonomy. Somehow then, the distinction between ideological and genuine recognition, if it can be made at all, will have to be drawn from within those social practices, as an appeal to a noumenal realm of freedom where we can rationally will what we ought to do cannot work. This is further complicated by the fact that both genuine and ideological recognition – being forms of recognition – must meet the approval of the subject in the sense that both must make the subject feel valued and are considered positive developments conducive to individual growth. Hence, the experience of the subject cannot help us here either. Ideological recognition then consists in practices that are “intrinsically positive and affirmative” yet “bear the negative features of an act of willing subjection, even though these practices appear prima facie to lack all such discriminatory features” (Honneth 2012, p. 78). How can these acts of recognition be identified?
The key seems to lie in the notion of ‘willing subjection’ and the possibility of identifying this despite subjects’ pronouncements of their wellbeing. The judgement that particular practices of recognition are ideological in the sense that they constitute acts of willing subjection must therefore be made by an external observer. The observer needs to perceive subjection, while at the same time explaining away the person’s acceptance of the situation as an indication that he has internalised his oppression in such a way that he willing subjects himself. The case of the ‘good mother’ is a case in point; by voluntarily endorsing that role, she remains uncompensated for her work and many other opportunities in life would be foreclosed to her. Now the observer, in this kind of theoretical narrative, is no longer concerned with the quality of interpersonal relations or the subject’s experience of freedom and wellbeing. What is at issue here seems to be that the observer disagrees with the values and beliefs that structure those relations, rather than the quality of those relations being relations of mutual recognition. A contemporary example can further clarify.
Consider the claim, often heard in certain public discourse, that Muslim women who cover their hair – who wear a hijab – are ‘oppressed’. Frequently, the claims made do not require that the women in question report any oppression, and hence concepts such as ‘internalised oppression’ are invoked to explain the lack of a negative experience. Of course, some women are coerced into wearing the hijab, and given the right context they would remove it and see it as an unnecessary imposition on them. For others the hijab is about modesty and has religious connotations. In this sense, it is not a symbol of their oppression and may even be regarded as a feature that can generate positive recognition as a pious and religiously observant person. An observer who claims that the desire for recognition in such cases is ideological – that women who cover their hair are willingly (and subconsciously) subjecting themselves to existing norms – is making a statement about his or her views on the cultural context: the problem the observer has is with the religious weight placed on clothing, or the fact that it is mainly women who have to observe such practices. Some women who wear a hijab reject this account since it bypasses their own understanding of what they are doing and the value they attach to it (in fact such an account can itself end up being a form of misrecognition). Not surprisingly, the exact claim is made in reverse by some Muslim women who argue that ‘Westernised’ women who dress ‘immodestly’ are oppressed by a dominant, male culture that subtly forces them to show their bodies. Those who believe that dressing in this way is an expression of freedom and secularism have simply internalised the values by which they willing subject themselves to existing norms.
The point of presenting this case from both sides is to show that once we bypass people’s accounts of what they are doing, and put aside their reported experience of freedom and wellbeing, we can see that what is going on is an ideological conflict between two worldviews. This conflict can itself be described within the framework of misrecognition as a continued devaluing of agent’s identities under the cover of an interest in their wellbeing. Of course, people are not always right about what they are doing, and our psychological depth is such that we can deceive ourselves and accept an abusive situation, even more not be able to see that it is abusive. We may convince ourselves that a particular role is exactly right for us, whereas others can see that it is obviously limiting our lives. But psychological depth and the possibility of self-deception go both ways; if that person over there is not transparent to himself then neither am I, even if transparency admits of degrees. Hence, if we are going to argue that a person is willingly subjecting herself, we also need to account for our motivations in making such an argument and what we are, in a sense, getting out of it in terms of validating our worldview, our take on what matters.
This perspective on the idea of ‘willing subjection’ should not be interpreted as a call for inaction; what it is, is a call for personalising and contextualising our moral and political responses and analyses of the lives of others. This means that if we are inclined to persuade individuals to change their understanding of their situation, then we cannot simply bypass their experience of wellbeing and their specific circumstances. In other words, sweeping judgements that take the form ‘group x is oppressed’ are not helpful; clearly there are all sorts of possibilities and the only way to sort these out is to be aware of this complexity, without losing sight of ‘structural’ discrimination in a particular community. With this in mind we will find that the spectrum of oppression includes the following: some in group x are oppressed and are already fighting to change that; some do not consider themselves oppressed but change their take on the situation once they are presented with a different analysis of it; some do not consider themselves oppressed – despite clear evidence to the contrary – yet no amount of persuasion can get them to see this; some consider your interest in their freedom as an attempt to oppress them; others consider themselves perfectly free and empowered.
Returning to our original question – the distinction between ideological and genuine forms of recognition – it appeared, to begin with, that the idea of ‘willing subjection’ held the key to that distinction. However, on having a closer look at this idea it emerged that what it communicates is a conflict of worldviews rather than a view on the quality of interpersonal relations as relations of recognition. As argued earlier, whether ‘ideological’ or ‘genuine’, if the relations in question are to be relations of recognition then the individuals concerned must feel valued for who they are, and be able to see existing relations as contributing to their personal growth and fulfilment. In this sense the distinction between ideological and genuine recognition cannot be drawn using the notion of ‘willing subjection’. What this notion brings to light are the very real, and very deep, disagreements in beliefs, values, social roles, and life goals that exist across contexts and ideologies. And while it certainly is of importance to debate and negotiate these differences, in order for such disagreements not to end up themselves generating conditions for misrecognition, it is necessary not to lose sight of the individuals involved, including their take on what they are doing and their experience of freedom and wellbeing.
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.
Over the course of last year I have been working on a small project with Rachel Bingham examining the possibility of distinguishing ‘social deviance’ from ‘mental disorder’ in light of recent work on concepts of health. The result was an essay published recently in the journal Philosophy, Psychiatry & Psychology (21:3-September 2014).
In our response to Moncrieff and Stein we found it necessary to point out that in the writings of some critical psychiatrists and psychologists there is a problematic conflation of empirical with conceptual issues in relation to ‘mental disorder’. That section is reproduced below. Note that Criterion E is the final clause in the DSM definition of mental disorder. It states that a mental disorder must not solely be a result of social deviance or conflicts with society.
Let us begin by revisiting the conceptual basis of attributions of mental disorder. Criterion E is not, as we argued with Stein et al. (2010, 1765), conceptually necessary, but is of ethical and political importance given the historical context. Thus, notwithstanding the other criteria, a condition can only be considered for candidacy for mental disorder if “dysfunction” is present. What is a dysfunction? As Moncrieff puts it, there is a tautology in the definition of mental disorder where it is stated that a mental disorder reflects an “underlying psychobiological dysfunction” (Moncreiff 2014). Moncrieff argues that this is flawed because underlying processes have not been established, which renders the definition tantamount to saying that a dysfunction is a reflection of a dysfunction: a definition that adds nothing to our knowledge.
Here Moncrieff follows Thomas Szasz in finding a lack of resemblance to physical disorder to be the primary problem with the concept of mental disorder (see Fulford et al. 2013).1 In pursuing this, the critical psychiatrist not only fails to see the complexity of the concept of physical disorder, but also commits the same error as the biological psychiatrist. The latter implies that an ever longer awaited complete neurochemistry of mental health conditions would solve the conceptual problems. The former—the critical psychiatrist—implies the converse; that the absence of proof for the “existence of separate and distinct foundational processes,” as Moncrieff (2014) puts it, proves that mental health conditions are not disorders. As we have argued elsewhere, identifying the biological basis for a set of behaviors or symptoms does not in itself pick out what is pathological or disordered: for example, a complete description of the neurochemical states governing sexuality would not permit the inference that homosexuality is a disorder, any more than discovery of the neural correlates of falling in love or criminality would make these mental illnesses (Bingham and Banner 2012). Neurobiological changes—their presence or their absence—tells us about conditions when we find them by other means, but it does not tell us what is or is not a disorder. The same arguments could be run for underlying psychological processes. Consequently, emphasis on scientific progress or failure to progress in understanding the neurobiological correlates of mental health conditions does little to advance the conceptual debates, a point that may help to explain the impasse in the ongoing exchange between critical and biological psychiatrists.
Thus, although Moncrieff is right in pointing out that the term ‘dysfunction’ is redundant in the definition of mental disorder, she is wrong about the reason why this is so. It is not, as she claims, due to the point that no “separate and distinct foundational processes” (2014) that can ground dysfunction have been discovered empirically. After all, this leaves her open to the simple response that they actually have been, a response many biological psychiatrists do offer. The redundancy of the term ‘dysfunction’ in the definition of mental disorder is a result of conceptual analysis (and not empirical evidence), whereby it has not proven possible to define dysfunction in a way that excludes values. Here, we follow Derek Bolton in the view that once we “give up trying to conceptually locate a natural fact of the matter [dysfunction] that underlies illness attribution… then we are left trying to make the whole story run on the basis of something like ‘distress and impairment of functioning’” (2010, 332). We are left then with those things that matter in real life, the reasons that lead to healthcare being sought: usually the presence of significant distress and disability.
This is what the terms ‘dysfunction’ and ‘mental disorder’ pick out once we achieve some clarity on their referents. Stein is clearly aware of the problems inherent in defining dysfunction. However, somewhat surprisingly, the assumption that we can talk of ‘dysfunction’ over and above experienced factors (distress and disability in particular) arises through Stein’s commentary. In other words, although Stein has acknowledged the conceptual problem, in places he still writes as if there were a clear definition of dysfunction, without telling us what this would be. For example, he describes “situations when there is evidence of dysfunction, but an absence of distress and/or impairment” and gives the example of tic disorders which have no “clinical criterion (emphasizing distress and/or impairment)” (Stein 2014). We would argue that, despite the lack of explicit acknowledgement in DSM, tic disorders enter the manual because of their association with clinically significant distress and disability. It is important to avoid confusing the empirical questions (e.g., Why do people have tics? Can people have tics and not be distressed?) with the conceptual questions (e.g., When is a tic a disorder? Can tics be disorders if they do not cause distress or impairment?).
A further potential pitfall is to conflate the technical use of ‘dysfunction’ with the ordinary use of that term. This might occur where, on the one hand, we perceive a ‘dysfunction’ but on the other hand we are unable to say what the dysfunction consists of. When Moncrieff writes that dysfunction and distress are not co-extant, because, “people may neglect themselves and act in other ways that compromise their safety and survival without necessarily being distressed,” she is offering a description of behavior many would consider ‘dysfunctional’ in the lay sense (2014). Considered as a basis for conceptual analysis, however, this does not illuminate any “underlying psychobiological dysfunction”, which previous definitions aspired to do. Indeed, it is somewhat surprising that Moncrieff provides this counterexample rather than sticking to her argument that dysfunction in fact does not exist. In citing safety and survival, Moncrieff’s phrase does resemble the evolutionary theoretic approach (notably described in Wakefield’s Harmful Dysfunction Analysis), which as has been discussed widely elsewhere and noted in our paper, has fallen out of favor owing to problems with evolutionary theory specifically and naturalistic definitions in general. What of importance is left in Moncrieff’s putative definition if not underlying psychobiological and evolutionary dysfunction? We would argue: only the harm or threat of harm experienced by the individual, whether that harm is cashed out as distress and disability or as some other similar negatively evaluated experienced factor.
In a recent polemic against certain increasingly dominant strands of phenomenological psychopathology, I launched a critique of the concept of ‘second-order’ empathy. This concept has been proposed by prominent psychopathologists and philosophers of psychiatry, including Giovanni Stanghellini, Mathew Ratcliffe, Louis Sass and others, as a sophisticated advancement over ‘ordinary’ or ‘first-order’ empathy. The authors argue that this concept allows us to refute Jaspers’ claim that certain psychopathological phenomena are un-understandable, by demonstrating that theoretical sophistication allows a ‘take’ on the these phenomena that reveals them as meaningful in the context of the person’s ‘life-world’. In my essay I argued that, given its philosophical commitments, the second-order empathic stance is incoherent, and given the constraints it places on the possibility of recognitive justice, it is unethical. The commentators take issue with both these points, to which I now respond.
First critique: ‘Psychopathology is not first philosophy’
In a succinct yet accurate summary of the first part of my argument the commentators write:
Rashed first addresses the issue of the feasibility of psychopathologists engaging in second-order empathy with persons with psychotic experiences/schizophrenia … [He] marshals textual evidence that psychopathologists can only make their case for second-order empathy by showing that it requires the performance of the Husserlian ‘phenomenological [transcendental] reduction’. Then, by citing phenomenologists such as Merleau-Ponty, as well as developing his own arguments, Rashed maintains that phenomenologists themselves do not agree that the phenomenological reduction is even possible. Assuming now that this conflicting reasoning demonstrates the impossibility of performing Husserl’s reduction, Rashed concludes that second-order empathy is impossible (because such empathy presupposes the successful performance of an impossible reduction).
Now their critique: the commentators begin by pointing out that the “‘transcendental reduction’ is designed to reach the level of a ‘transcendental consciousness’, which is the subject matter for a ‘first philosophy’ (namely, transcendental phenomenology) [that] can supply the foundation for all of knowledge”, a characterisation with which I am in agreement. I would go further and state that I consider, together with a long line of modern philosophers from Hegel to Wittgenstein, that such a project cannot work: we cannot get behind knowledge in order to establish the grounds for certainty of knowledge. As Hegel put it in his Logic, to aim to investigate knowledge prior to attempts to know the world is “to seek to know before we know [which] is as absurd as the wise resolution of Scholasticus, not to venture into the water until he had learned to swim”. The commentators then go on to state, in criticism of my essay, that psychopathology is not ‘first philosophy’. To examine, as I do, the “quarrels among phenomenological philosophers about the founding level of phenomenological inquiry” and the possibility of the transcendental reduction, is to burden psychopathology with irrelevant problems. Hence, they write, psychopathologists “can breathe a deep sigh of relief”. I suggest they hold their breath. Psychopathology is not ‘first philosophy’ – I whole heartedly agree with this statement – but in order to establish its basis and validity, phenomenological psychopathology helps itself to the entire Husserlian philosophy, and therein the problem lies.
What is psychopathology? It is a formalisation of abnormal folk psychology : it is the meticulous documentation of mental states and their connections – or lack thereof – and in this sense has no special claim to expertise on mental states except in so far as meticulous documentation can be illuminating. Put differently, psychopathology cannot overstep the soil or ground from which it arises – namely, folk psychology – and claim knowledge of the supposed ‘true’ nature of ‘abnormal’ mental states. But that is precisely what contemporary phenomenological psychopathology wants to do. It is not content with psychopathology being a formalisation of folk psychology and hence dependent on it; it wants psychopathology to be a ‘science’ that exceeds folk psychology and from which the latter can learn. In order for psychopathology to be a ‘science’ it claims a theoretical basis that is not available to folk psychology. It establishes its credentials as a ‘science’ by helping itself to the entire Husserlian philosophy: it helps itself, in particular, to the concept of the ‘transcendental reduction’ without which the proposal for ‘second-order’ empathy as a mode of philosophically articulated understanding of others would not work. (I argued this final point in detail in my essay: achieving second-order empathy requires as a first step that one suspends the natural attitude and grasps that the sense of reality with which experience is ordinarily endowed is a phenomenological achievement, a move which presupposes the possibility of the transcendental reduction.)
Shorn of its theoretical ‘transcendental’ basis, psychopathology falls back to earth as the discipline which meticulously documents mental states and their connections in accordance with the implicit rules and principles of a particular folk psychology (particular since the rules and principles in question are normative and subject to, among other things, the influence of ‘culture’). Psychopathologists may be better in this than others, but that is because they have made it their vocation, and not because they have somehow ventured beyond folk psychology. Indeed, somewhat ironically, the commentators’ own account of how understanding works proves my argument that all we’ve got is ‘first-order’ empathy, of which the qualification ‘first-order’ can now be removed as there is nothing left to contrast it with:
Jaspers realized that, in order to apply the phenomenological method (in this less demanding sense), I first need to ‘evoke’ the perspective of the other in my own consciousness. This evocation is not some kind of (‘mysterious’) self-immersion into the other’s psyche, but a meticulous and often strenuous (and necessarily imperfect) hermeneutical reconstruction of the other’s mental life (i.e., drawing on my own experiences and elaborate narrations of the pertinent experiences in order to get a ‘feeling’ for the other’s mental life).
Indeed: empathic understanding involves a “hermeneutical reconstruction of the other’s mental life”, a reconstruction in which I draw upon “my own experiences”. It seems then that the commentators’ disagreement with the first part of my essay is not as intractable as it first appeared to be. However, the important point to reiterate is that phenomenological psychopathology faces a dilemma: either it holds fast to its basis in transcendental philosophy and hence becomes theoretically incoherent, or it abandons its pretentions to be a ‘science’ and hence, as indicated, rest content with what it is: a formalised folk psychology. In my view, given the arguments of the original essay, only the latter option is available. And contrary to what it may seem, that is not a bad position to be in; far from it. The documentation of the various states of the mind, their description and the search for connections among them, while that is a vocation that cannot exceed folk psychology, it can certainly make available for the ‘folk’ certain possibilities of human experience and belief of which they were not explicitly aware, and therein its value may lie.
Second critique: ‘Distinguishing methodological from ethical value’
In the second part of my essay I considered the ethical dimension of the second-order empathic stance. I asked if an attitude which emphasises radical difference – as required by this stance – is the right one to hold towards persons diagnosed with schizophrenia. My answer was that it is not, but the reason why this is so is important and deserves restatement. An attitude which emphasises differences is not the right one to hold, not because such emphasis is bad in itself; I would, for example, consider an attitude which emphasises similarity as also potentially problematic. This is because the issue at stake is not the nature of the attitude, but the degree to which the persons who are at its receiving end have had a say in its construction. The reason such a consideration is normatively significant has to do with the necessity of reciprocal relations of recognition for identity formation and self-realisation. To have an academic discipline launching discourses about others cloaked in the technical jargon of phenomenological philosophy, and possessing of the prestige and authority of scholarly argument in general, is to give those others no real chance and no say in how they would like to be represented. This is not a call to ban certain words or discourses – of course not! But it is a call to appreciate that there is no ethically neutral discourse or methodology. Unfortunately this neutrality is precisely what the commentators seem to be arguing for in critique of the second part of my paper.
They begin by stating that emphasising differences is important as this may ultimately enable the psychiatrist to understand his or her patients:
On the contrary, we assert that psychopathology emphasizes difference in order to encourage the examining psychiatrist to keep on going in the attempt to understand even when such understanding seems to have ‘reached a brick wall’. Examining psychiatrists should keep on going even when they fear that they have hit a limit inherent in understanding the patient.
Now this argument seems to rest on an assumed value being attached to understanding others. They restate their point again as follows:
It is valuable to be aware of the differences of persons with psychotic experiences/schizophrenia and typically ‘‘normal’’ persons, and consequently, to persist in the task of understanding.
They go on to describe the value in question as a ‘methodological’ value and distinguish this from the “ethical value of the person with psychotic experiences/schizophrenia [which] is the same as the ethical value of the rest of us”. I admit I find such a pronouncement somewhat unusual, as it implies that our methodological approaches towards others can be disentangled from our ethical evaluations towards them as long as we insist that they are our equals. If only it was this easy.
Understanding others is not merely of ‘methodological’ value: it is ultimately a core issue in any normative moral theory, and hence much broader. The distinction drawn by the commentators between methodological and ethical value suggests that it doesn’t matter what approaches we adopt towards others as long as we are motivated by understanding them, and never lose sight of the fact that they are our equals. Once seen as a concern with how we should treat others, such a picture appears naïve. For one thing, over and the above the need to understand, lays the wishes of those we are trying to understand: they may wish to have a say in how they would like to be understood, and in the language and method which they consider more representative of who they are. All this is to say that there is no domain of human interaction that lies, as it were, beyond the ethical. Phenomenological psychopathology cannot hide behind this claim to ethical neutrality, irrespective of whether or not it is methodologically valuable.
Mohammed Abouelleil Rashed – May 2015