From The Philosopher, vol. 110, no. 3 ("The New Basics: Person").
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Is madness a pure deficit to be cured or managed? Is it merely an expression of the loss of reason, an obstacle to free action, and an impediment to social participation? Or can it have value in the sense that it can be accommodated within our conceptions of autonomy, mind, identity, personhood, and sociality, conceptions that make up what a society considers to be a good or a natural life? Much hangs on our answer to these questions. On a deficit view, madness would be excluded from the valued conceptions of our humanity, as somehow lying at their limit or outside them altogether. It would be to say that there is nothing that madness, as madness, can contribute to knowledge. Even more, that madness can be a threat to a social life that requires assent to norms and common-sense beliefs. But if madness can have value, it would then be included within our valued conceptions as a possible – albeit complex and often distressing – configuration of our humanity. What, then, is madness?
In common usage madness is a non-technical term for “mental illness”. It denotes irrationality, poor judgement, and loss of contact with reality. All three notions are reflected in the colloquial idea that mad persons have “lost their mind”, that they are unable to form sensible beliefs, are vulnerable to hallucinations, are prone to surrender control of their thinking and action, and are constrained by extreme emotions. This view contrasts with how some mental health activists and academics understand madness. In the edited collection Mad Matters (2013), Maria Liegghio refers to madness as:
…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 [psychiatric] 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.
These two views reflect a deficit versus a value understanding of madness. While both views conceive of madness as forms of experience and belief that correspond, roughly, to the psychiatric categories of schizophrenia, psychosis, and bipolar disorder, they ultimately take a different attitude towards these experiences and beliefs. How, then, have philosophers typically understood madness?
Throughout its history, philosophy has tended to exclude madness and to place it squarely in the deficit camp. For example, in the Timaeus, Plato described madness as a “disease of the soul” that renders the person incapable of reason. In his Meditations on First Philosophy, René Descartes regarded madness as the loss of reason and the inability to represent reality, while the theme of deficit is also present in Immanuel Kant’s Anthropology from a Pragmatic Point of View, where various forms of madness (along with certain racial categories) were associated with deficiencies in the faculties of cognition, feeling, and desire. More recently still, Ludwig Wittgenstein’s On Certainty presented madness as the endpoint of philosophical inquiry, a radical departure from common-sense. We can refer to this philosophical form of exclusion as “epistemic”, as it has the implication of eliminating madness as a possible source of knowledge.
Throughout its history, philosophy has tended to exclude madness and to place it squarely in the deficit camp.
Alongside this epistemic exclusion, madness was, and continues to be, excluded from various normative moral and political theories. Normative theories are concerned with the central philosophical questions of how we should act and what we owe each other. These theories speak to our humanity and to particular capacities within us. They aspire to guide our moral and political behaviour in line with their core ideas. For example, Kantian moral theory speaks to our capacity for reason as a basis for rational self-governance (autonomy); Neo-Aristotelianism and virtue ethics speak to our capacity for virtue, compassion, and empathy; and theories of social recognition speak to our capacity for forming and maintaining an identity. Madness is excluded from all of these theories due to the assumed inability to satisfy the capacities in question: reason- and autonomy-based accounts exclude madness owing to irrationality and impaired decision-making capacity; virtue-based accounts exclude madness owing to disruption of interpersonal understanding and empathy; and recognition-based accounts exclude madness owing to impairments of identity formation.
One key implication of this exclusion is that normative moral and political theories can speak about but never to madness. The mad person is not considered a possible enactor of the theory: he can receive moral and virtuous treatment, but he cannot reciprocate it. This predicament underlies the excuse offered to the mad person from the duties that we expect of moral agents. And it justifies the forms of coercion and deprivation of liberty to which mad people are subjected. In this way, the exclusion of madness from normative moral and political theories has the implication of constraining mad persons’ moral and practical agency.
The philosophical exclusion of madness on epistemic and normative grounds has its counterpart in a social exclusion, both physical and cultural. Persons considered to be mad or insane have for centuries faced maltreatment and stigma, a point demonstrated by the Survivor History Group in a timeline that begins in 1373. But the social exclusion of madness as it played out from the early decades of the 19th century up to the middle decades of the 20th century was unprecedented in terms of the rapid increase in the number of asylums and their population, and the gradual dominance of expert narratives about madness.
The exclusion of madness from normative moral and political theories has the implication of constraining mad persons’ moral and practical agency.
Between the middle of the 18th century and the end of the 19th century, the number of asylums in England rose from 3 to 120. Prior to this, most people who would have been considered insane were managed in private madhouses or by their families. This was set to change in 1808 when the English Parliament approved the public funding of asylums and obliged all counties to build one. By 1954, 150,000 people resided in asylums, a number that, when adjusted for the population difference, is seven times more than the asylum population in 1800.
Irrespective of the care delivered within them, and whether it was humane or otherwise, asylums represented powerful physical markers of exclusion. Madness was outright removed from society and managed on the outskirts of counties. It was no longer seen or interacted with in everyday life – out of sight, far from view, and gradually culturally unintelligible except to the experts who took charge of classifying, theorising, and managing it. And at around the same time as the physical exclusion of madness was peaking, its cultural exclusion was beginning to take hold.
By the middle of the 19th century, there was a shift away from moral and religious approaches to insanity and towards bodily and secular explanations, so that by the turn of the 20th century the bases for diagnostic-scientific psychiatry and talking therapies were already being laid down. A key result of these transformations was the development of an expert narrative about madness, with the language led by terms such as mental-disease, -pathology, -illness, -disorder, -dysfunction, and various kinds of abnormal psychological mechanisms.
These developments can be seen as part of the large-scale cultural transformation referred to by Charles Taylor in A Secular Age (2007) as the “therapeutic turn”, as a result of which “certain human struggles, questions, issues, difficulties, problems are moved from a moral/spiritual to a therapeutic register … from a hermeneutic of sin, evil or spiritual misdirection, to one of sickness”. The cultural exclusion of madness was a result of the decline of moral, religious, and traditional approaches, such as spirit possession, at the same time as the emergence of a new technical narrative. Madness had come to be the province of the experts, largely incomprehensible to the public.
By the 1960s, we can see the beginnings of transformations that problematised the modes of social exclusion dominant at the time, both physical and cultural. The popularity of asylums declined, and political decisions prompted their gradual closure. Aiding this was the discovery of the Phenothiazines, a class of drugs that reduced agitation and symptoms of madness, and which were initially referred to as major tranquilizers and subsequently as antipsychotics. In 1971, care in the community was officially heralded by a British government paper proposing the closure of all asylums and the delivery of care by general hospitals, outpatient clinics, family doctors, and social services. Today, in the UK, mental health care continues to be delivered in a similar manner, supported by several secure and specialist units.
It was in the early 1970s that civil rights activism in mental health experienced a resurgence. Activists at the time sought to restore full civil rights to mental patients and to end involuntary incarceration in asylums and forced treatment. They also campaigned to end the dominance of medical approaches and language in the public understanding of mental suffering. With the asylums closing, activists began referring to themselves as “ex-inmates”, rejecting the term “patient” with its connotations of care and cure. In the 1980s, the term “service-user” emerged, and remains with us to this day, yet this term has always been rejected by some activists who think that it wrongly suggests an equal relation between patients and mental health professionals. “Survivor” identity was born partly as a response to this and marks an important shift in mental health activism. It emphasises the positive attributes of survival such as strength and resilience, and it prioritises the voice of survivors and their ability to tell their own stories.
The ambitious goal of Mad Pride is cultural change in the way madness and normality are perceived.
The late 1990s and early 2000s saw the emergence of the discourse of Mad Pride, a radical grassroots challenge to the language of mental illness and the social norms underlying it. The ambitious goal of Mad Pride is cultural change in the way madness and normality are perceived. Activists resist the medicalization of madness by rejecting the reductive language of mental illness and mental disorder, and reclaiming the term “mad”. They seek to enrich the cultural understanding of madness by creating counter-narratives, or Mad narratives, of psychological, emotional, and behavioural diversity.
Mad narratives aim to register, in equal measure, the suffering as well as the potential value afforded through voices, visions, and states of heightened salience and sensory awareness. Among these narratives, there is acknowledgement that modes of cognition that emphasise the interconnectedness of meanings and events can lead to the labyrinth of a persecutory delusional system but can also lead to concern for the welfare of others and the state of our ecosystem; hearing voices can imprison a person in a world of threats but can also lead to valuable self-knowledge; and extreme states of mood elevation can lead to disorganisation and despair but can also lead to creativity and boundless energy. In the words of the Icarus Project, madness is a “dangerous gift”. Mad narratives seek to make room for madness within our conceptions of human nature, and in doing so to address the cultural element of the social exclusion of madness.
What, if anything, can philosophy offer to these tentative attempts to include madness within our valued conceptions of human nature? As a starting point, philosophy needs to reckon with the part it has played, and continues to play, in the epistemic and normative exclusion of madness. In this sense, philosophy is part of the problem, but it can be part of the solution. There was a notable resurgence of philosophical interest in madness, psychiatry, and mental health since the 1980s, and while this was not necessarily the starting point of this reckoning, it certainly prepared the ground for it. Until very recently, the field of philosophy of psychiatry remained more-or-less bound to the deficit view of madness. Philosophers certainly produced sophisticated analyses of, among other topics, the concept of mental disorder, of meaning and causation, and of delusions and hallucinations. But the underlying assumption was that of madness as a deficit to be explained and interpreted, and the language in which these analyses were conducted was that of mental illness and disorder.
Philosophy needs to reckon with the part it has played, and continues to play, in the epistemic and normative exclusion of madness.
What is equally notable about the philosophy of psychiatry from the 1980s up to the 2000s was the absence of the voice of service-users and patients. And when their words did make an appearance (as they often did in the sub-discipline of phenomenological psychopathology – see, for example, the work of Giovanni Stanghellini or Louis Sass), it was much like the appearance of exotic psychological curiosities, unintelligible through everyday concepts and meanings. It is still commonplace for philosophers and psychiatrists working within this framework to use first-person narratives of, say, patients diagnosed with schizophrenia as puzzles that need to be rendered intelligible through the application of philosophical ideas from the continental tradition in phenomenology. And so the person’s words, their accounts of their experiences, are distorted into a jargon-laden interpretation courtesy of Martin Heidegger, Maurice Merleau-Ponty, Edmund Husserl, and other European phenomenologists.The resulting philosophical accounts of schizophrenia and other conditions can thus end up being as alienating as the reductive biological accounts of mental illness they were seeking to challenge and undermine.
The framework of epistemic injustice illuminates the often unjust loss of credibility patients suffer by virtue of having a psychiatric diagnosis.
It is in relation to these concerns that we find promising developments in recent work in the philosophy of psychiatry. This work can be thought of as trying to halt the impulse to understand madness at all costs, where the cost has often been the radical distortion of the person’s voice. Two concepts have been particularly helpful in this regard: epistemic injustice and misrecognition. Epistemic injustice (a concept formulated by Miranda Fricker) refers to the harms done to persons when their standing as producers of knowledge is undermined. In the context of mental health, the framework of epistemic injustice illuminates the often unjust loss of credibility patients suffer by virtue of having a psychiatric diagnosis, and it alerts us to the lack of a publicly available language by which they can understand their experiences in a positive light. Misrecognition refers to cultural understandings and social relations by which people can be trapped in devalued and stigmatised identities. They become socially invisible, or socially visible in a way that does not correspond to how they wish to see themselves. In mental health, the concept of misrecognition illuminates the impact of medical language on social identity and on persons’ abilities to find value in their experiences. Both concepts support the demands of some activists towards public recognition of new mental health identities, no longer grounded solely in the language of deficit.
Beginning to think about mental health through the concepts of epistemic injustice and misrecognition is just the start. There is much more work to be done to understand the obstacles standing before the accommodation of madness within the valued conceptions of human nature. In order for this process to have a fair chance, whatever the results, we need a shift in attitude: the valued conceptions of human nature – our understanding of identity, personhood, autonomy, sociality, and rationality – cannot be held as the yardstick against which madness is measured and always found wanting. We must question our understanding of these notions and their limits, at the same time as asking whether there can be room for mad forms of cognition and experience within them. This is where we might find an answer to the question we started with: is madness a pure deficit or can it have value?
Mohammed Abouelleil Rashed is a researcher and lecturer in philosophy and psychiatry. He currently practices psychiatry at a community mental health team in North London and is a Visiting Lecturer in Philosophy at King’s College London. He is the author of Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism (Oxford University Press, 2019).
From The Philosopher, vol. 110, no. 3 ("The New Basics: Person").
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