International Perspectives in Philosophy and Psychiatry
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Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism
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Madness and the Demand for Recognition
A philosophical inquiry into identity and mental health activism
Mohammed Abouelleil Rashed
Wellcome Trust ISSF Research Fellow, Department of Philosophy, Birkbeck College, University of London, United Kingdom; Visiting Lecturer, Department of Philosophy, King’s College London, United Kingdom
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For Rachel
And the moments when Iʼd been soaring with eyes full of horizon and a heart branded like a contour map with the outlines of rocky sunrises and the fractal branching of so many threads of understanding . . . these seemed like the most important moments of my life. I didnʼt want to chalk them up to pathology, give them ugly labels like mania and delusion that seemed to invalidate them, make them less real. I didnʼt want to eradicate them all for the sake of “stability” . . . Yet as much as I resisted their words, they were all I could find, and over and over again these incredibly limited, awkward words seemed like the barest blueprints to my soul.
Jacks Ashley McNamara, artist and activist
Thou only hast taught me that I have a heart—thou only hast thrown a light deep downward, and upward, into my soul. Thou only hast revealed me to myself; for without thy aid, my best knowledge of myself would have been merely to know my own shadow—to watch it flickering on the wall, and mistake its fantasies for my own real actions.
Nathaniel Hawthorne, a letter to Sophia Peabody October 4, 1840, ½ past 10 A.M.
Foreword
Honored with the task of introducing this exemplary volume—an important book, at a critical time—I want to begin by placing Mohammed Rashed’s project within its historical and disciplinary context, before drawing attention to some of its most notable, and admirable, qualities.
Mental health and ill health intersect with a host of traditional philosophical concerns—reductionism, agency, responsibility, knowledge, belief, rationality, and self-identity, to name a few—and since the last quarter of the twentieth century, philosophical attention has been drawn to the ways mental disorder confounds, and illuminates, these and allied concepts. By the 1980s and 1990s, philosophy and mental health, or as it was more often known in the United States, the philosophy of psychiatry, emerged as a distinguishable research area within academic philosophy, affording focused conferences and associations, specialized monographs and collections in scholarly presses, and a widely respected scholarly journal.
From the start, the new research field was eclectic, notably broad in its interests and methods, and contentious. Unlike many medical conditions, mental disorders are rarely (or arguably, never) a-symptomatic. Nor, thus far, can they be verified independently of first person symptom-descriptions. And this distinctive epistemic feature has fostered involvement with phenomenological ideas inherited from thinkers such as Husserl, Heidegger, Jaspers, and Merleau-Ponty. Within psychology during these decades, in addition, a functionalist cognitivism and neuroscience, agreeable to philosophical language and presuppositions, came to replace behaviorism. Beyond these very general trends, the subareas of philosophy registered particular challenges posed by psychopathology. Philosophers of science have refined their conceptions of kinds through a consideration of mental diseases, for example. The treatment and care of the mentally ill have attracted the attention of bioethics. Those analyzing agency recognized the puzzles raised by addiction. And traditional analyses were required to acknowledge the anomalous epistemology of delusions. Disagreement here has always been wide, and deep. Undertaken alongside an increasingly biological and reductionist medical psychiatry and neuroscience, much of this work accepts, or makes peace with, the diagnostic categories and methodological presuppositions of models employed by medicine, where those with mental disorder are construed as blameless victims of misfortune, indistinguishable from people disabled by other forms of ill health, and as dependent on their medicines as the diabetic on her insulin. Irreconcilably contrary, meanwhile, were the antipsychiatry claims of Szasz, Laing, Foucault, and the feminists. Mental illness was not an illness at all; medical psychiatry was an organized, predatory force, to be resisted.
Concurrent with such theoretical inquietude during those decades, radical, realworld changes were taking place. The effects of the 1970s mental patients’ rights
movement (along with other factors) had emptied the asylums. Psychopharmacology increasingly rendered physical restraints unnecessary and, at least in the eyes of many, left long-term psychotherapy otiose. In the clinic, appeal to psychoanalytic and psychodynamic ideas was being replaced by evidence-based psychiatry. And, as Mohammed Rashed documents in his opening chapter, the power of collective political action was making itself felt by those sharing what is today politely termed a “mental health history.”
In all the otherwise eclectic, wide-reaching, and take-no-prisoners theoretical discussion, little philosophical attention was given to the words of consumers, survivors, and users, or to the rhetoric emerging from political interest groups formed by those subject to psychiatric diagnoses and treatment. Following Descartes’ infamous remarks in the First Meditation, these voices were assigned the epistemic role of incomprehensible ravings, when not entirely ignored. Even as first person accounts of the experience of disorder were increasingly acknowledged to be an indispensable resource, and long after mental health services had begun to include consumers and service users in advisory roles, this more politically toned rhetoric was side-lined, and largely neglected in academic and theoretical research—within psychiatry, as we can perhaps more readily expect and understand, but also within the Philosophy of Psychiatry and of Mental Health.
In light of such neglect by others theorizing about mental disorder, that Mohammed Rashed has chosen to consider the claims arising from these consumer and user movements, is itself noteworthy. Equally noteworthy is that among the diverse range of claims arising from these movements, he has chosen to focus on the most radical version: not the request for less stigmatizing language; not the polite call for a seat at the table (“nothing about us without us”), or claims of authority derived from first-hand experience of symptoms; not the indignant complaint expressed by “survivors” of the mental health treatment that injustice has been done, and their semantic authority nullified; not the request for equality of mental with other disabilities, or the call for evenhanded consideration of neuro-atypical and neuro-typical traits. Rashed’s particular, and particularly confronting focus is on the credo that madness is an identity, arising from its own distinctive culture, and worthy of full political and interpersonal recognition. In the “mad and proud” attitude of what is here named mad-positive activism, madness is an attribution from which to draw strength, comfort, and self-definition.
This decision is part philosophical and part historical: Mad Pride is both the latest wave of activism, as Rashed points out, but also the one that makes the most serious demand on social norms and understandings. In addition, I would add, it evokes a Western cultural preoccupation. That amidst all the suffering, compromised practical and emotional functioning, and cruelly discriminatory treatment, madness has a compensating, glamorous aspect, is a long-recognized link, and one not lost on madpositive activists, with their talk of “dangerous gifts.” The haunting question from the pseudo-Aristotelian Problems (Why is it that all brilliant men suffer from melancholia?) reoccurs through the ages: through Galen, Ficino, Shakespeare, Burton, and the Romantics, to the early twentieth century. (Even Freud, the aspiring scientist, assigns to the melancholic “a keener eye for the truth.”) Bespeaking the spare normative economy of the eighteenth century, these once-valued compensations have today been
demoted—what is glamor, compared to pain and uselessness? Art and culture may be served by rare cases of manic inspiration; but overall, mental disorder must be judged to possess unmitigated disutility, both in the suffering it brings (or portends), and in its aggregative effects on productivity. The link to creative energy, exuberance, and profundity of thought and feeling, has been largely severed. (In a cynical exception, drug companies list the mad geniuses of the past to enhance sales of antidepressants.)
As well as taking on the most philosophically challenging and current of these activist viewpoints, then, the following work serves to remind us of themes from our cultural past that have been all but eclipsed by modernity.
Approaching this set of ideas with meticulous care, Rashed explores, dissects, explicates, and interpolates the claims of mad activism, exposing their theoretical implications, and allowing us to see their philosophical force. As well as situating them within mainstream philosophical research on mental disorder, he relates them to a body of theory that had not previously thought to examine them, Hegelian descendants from the social theory of thinkers like Honneth, and Taylor. And he subjects the whole to a thorough and respectful critique that is an exemplary model for how theorizing about mental disorder ought to be undertaken. Madness and the Demand for Recognition is, I believe, of the utmost importance to research developments in the philosophy of mental health and psychiatry. In the current era of identity politics, it shows the way through to a more complete and comprehensive application of philosophy to both medical science and real-world political culture.
Defining, understanding, and critically assessing Mad Pride, the following pages show, is a complex endeavor. The nature of recognition; the casual equation of identity with culture; the claimed analogies linking contemporary pride, and disabilities rights movements; the interlocking aspects of identity formation and capacity, and the place of self constructs in relation to these; and the value and scope of the “cultural adjustments” that go beyond prevailing medical conceptions of disorder each demand patient, nuanced analysis, and theory-informed interpretation. There are no easy answers here, and Rashed offers none. Yet he has given us a discussion that is fair, compelling, intelligent, and sympathetic. He also provides a detailed way forward, identifying what could work, and what can and should be done—a burden, he shows, that falls as much, or more, on the broader society, as on those who would forge mad identities for themselves. Those identifying as mad could not hope for better philosophical treatment, nor for a fairer and more useful analysis of, in his words, how to reconcile madness and society, in light of the polarities that have made Mad Pride a fiercely contested idea.
Jennifer Radden
Emerita Professor of Philosophy, University
of Massachusetts, Boston
Preface
I find it telling that the concept of mental illness tends to be applied to individuals and not communities. We have seen attempts to apply it to groups of people, to characterize some societies as “sick” or “deluded” by virtue of their barbaric practices and ideological commitments. But such claims can only be taken metaphorically, the power of the metaphor deriving from the meaning of these terms in the individual case. In psychiatric practice, one person can be deluded, two persons can be deluded—perhaps even three—but at a certain increment of numbers we no longer find it appropriate to continue using these concepts: we talk, instead, of cultural and ideological differences. Why is this so? There is no doubt that being part of a group protects, and doubly so. It offers a context of mutual affirmation of one’s experiences and convictions. And, from the outside, it proves that the persons involved in this group, irrespective of what we think of their beliefs and practices, are capable of forming a community; they possess the capacity for sociality, a capacity whose absence is often considered the hallmark of certain mental health conditions. If the group protects, how is society to respond to attempts within mental health activism to form communities, to transform the meaning of conditions typically considered to be mental disorders, to present madness as grounds for culture and identity, and to demand recognition of the validity and value of Mad culture and Mad identity: How is society to respond to Mad Pride and madpositive activism? I wrote this book to attempt to address this question. When I began to consider an answer to this question, I was struck by the complexity and range of the issues that I had to engage with in order to be able to address it satisfactorily. To begin with, there is the need to come to an understanding of the claims and demands of Mad Pride and mad-positive activism (Mad activism), and to place them in relation to past and current approaches in mental health advocacy and activism. Then there is the problem of how to reconcile the view of madness as a disorder (or a dysfunction or an illness) of the mind—as a set of phenomena that cause significant distress and disability—with the view that madness can be grounds for culture and identity. Then there is the presentation of the demand as a demand for recognition, which immediately raises thorny philosophical issues concerning the meaning of recognition, why recognition matters, the justification and adjudication of demands for recognition, and the various ways in which society can respond to them. Beyond all this, there is the challenge of reconciling madness—often assumed to manifest in various impairments in identity formation—with the understanding of identity presupposed by the theory of recognition. And, finally, there remains the question that began this cascade of concerns: How should society respond to Mad activism’s demand for recognition?
The range of issues just outlined meant that I had to venture into academic disciplines and philosophical traditions and concerns that have not been sufficiently
recognized in the philosophy and psychiatry literature. The resurgence of philosophical interest in psychiatry and mental health since the mid-1980s has been associated with a distinctive set of important concerns that include: the definition of the concept of mental disorder; the boundaries of illness; the philosophical phenomenology of the various mental health conditions; issues in philosophy of science such as causality, explanation, and classification; ethical issues in psychiatric practice; intersubjectivity and empathy in the clinical encounter and in specific mental health conditions. This book draws upon these research fields as required and, in addition, upon the following literatures: the activist literature, Mad studies and Disability studies literatures, and philosophical literature on the concepts, theories, and politics of identity and recognition. The latter, in particular, is notable by its relative absence in philosophy and psychiatry. I am referring here to a tradition of philosophical thought on recognition, freedom, and identity that finds its roots in the work of Georg Hegel and Immanuel Kant, and continues in the present day through the work of Charles Taylor and Axel Honneth, with alternative perspectives by Nancy Fraser, Kwame Appiah, and Richard Rorty, among others. By engaging with this literature, I developed in Part II a theoretical framework for thinking through the complex issues noted earlier and addressed in Parts III and IV of the book. In addition, I hope to have provided a formulation of identity and recognition that can be helpful for philosophers and social theorists grappling with other problems in mental health and psychiatry and with social movements in general.
It is common to refer to every current wave of activism as the final frontier in social change. I would not use that phrase, not only because it has so often been misused, but because there is no telling how far society can and will change, or what the next set of social shortcomings and accompanying demands for redress are going to be. But one thing I have no illusions about in writing this book is that the topic it deals with is controversial. Constructions such as Mad Pride and Mad identity tend to evoke passionate reactions, ranging from unconditional acceptance of such constructions to accusations that they are oxymoronic and incoherent. Partisan responses of this kind tend to characterize controversial issues in general; we have seen them and continue to do so in many of the pressing social issues of our time such as climate change and gay marriage. People tend to fall on one side or other of the issue, which limits the possibility of rational assessment and debate. In the domain of mental health, we see this today in the so-called diagnosis wars carried out on social media, and most clearly illustrated on Twitter. Psychiatrists and critical psychologists are pitted against each other, constantly arguing past each other, with one side seeing psychiatric diagnosis as a helpful or indispensable tool for providing mental healthcare, and the other side seeing it as an artificial construction that prevents mental health practitioners from understanding the social and political origins of mental distress. Mad activism is too important and far-reaching to be stuck in a similar closed circle of partisan commitments. It would be foolish to suggest that a book can provide a solution for this problem, but I hope that it manages to provide a philosophical framework for reconciling skeptics and supporters of Mad activism or, at least, to clarify their genuine loci of disagreement. Accordingly, in some respects, I see my role as one of mediator, and I bring to this role various aspects of my experience and learning. In my philosophical training I spent
much time thinking about the concept of mental disorder, the boundaries of illness, and the phenomenology of the conditions referred to in psychiatry as schizophrenia and bipolar disorder. Before moving on to fulltime research, I trained in psychiatry in London on the Guy’s, King’s College, and St. Thomas’ hospitals training scheme. I worked for a few years on acute inpatient units, rehabilitation units, and outpatient clinics. I witnessed the immense suffering and the cognitive and emotional challenges associated with the various conditions that doctors treat. On the other hand, I was aware that there was something fundamentally lacking in the rather austere, limited language of clinical psychiatry, and its one-size-fits-all approach. It did not describe my experience of the world, or that of many others. In my research I began thinking about alternative approaches to psychiatry, and I conducted an ethnographic study of a community in the Dakhla Oasis of Egypt where there was no mental health provision. I experienced an alternative cultural system where people understood and managed the range of mental health phenomena through entirely different narratives and social structures of healing and support. I was able to see the benefits and drawbacks of such systems. My experience as an ethnographer is key to how I view the endeavors of Mad activism, which I regard as attempts to broaden the cultural repertoire as it pertains to madness beyond medical and psychological models of illness, an issue that I address in Part IV. My intention throughout this book has been to engage fairly and respectfully with the claims and demands of Mad activism. Mental health is something that concerns all of us, and creating a society where there is a diversity of narratives in which people can find themselves is an important aim. In this respect, reconciling madness and society is a worthwhile goal, and I hope this book contributes toward that goal.
Mohammed Abouelleil Rashed London, January 2018
Acknowledgments
I began working on this book in 2013, but the ideas and experiences that led me to think about the issues in its pages go further back. In those years I have been influenced and inspired by far too many people to be able to mention them all here. I must begin by thanking the generous people who had shared their stories with me during my time as a clinician in London and as an ethnographer in the Dakhla Oasis of Egypt.
Special thanks to Derek Bolton and Werdie van Staden for their mentorship and friendship. I have learnt a lot from their knowledge of philosophy and psychiatry and from their wisdom—their keen sense of what is distinctive about our field and why it matters. Our discussions and collaborations along the years have certainly shaped my intellectual views and commitments.
Parts of this research were carried out while I was a research fellow at three institutions: the Institute of Advanced Studies (IAS) at University College London; the Division of Philosophy and Ethics of Mental Health at the University of Pretoria; the Department of Philosophy at Birkbeck College, University of London. I am grateful to my colleagues at these institutions for their engagement with, and feedback on, various presentations of my work. In particular, I would like to thank Tamar Garb, director of the IAS, for the stimulating research environment she had created at the Institute and for the opportunity to be part of it. I am also grateful to James Wilson for his guidance and support during my time at the IAS. Since 2008 I have been a member of a philosophy of psychiatry group composed of King’s College London alumni. On many occasions, I have had the opportunity to present my research and to discuss ideas with the group. Thank you for your valuable feedback. I would like to thank Werdie van Staden, Derek Bolton, and Rachel Bingham for reading and commenting upon parts of the manuscript. Special thanks to Chetan Kuloor and Amr Shalaby—they know why.
As the coming pages attest, I have been hugely influenced by the rigorous and subtle philosophical work of Jennifer Radden. Her writings on identity and mental health have been key to my understanding of these issues. I am greatly honored to have her introduce my book. Another obvious debt is to Charles Taylor, for it was on reading his essay “The Politics of Recognition” several years ago, that I acquired an entirely new perspective for thinking about mental health, madness, and society.
Thank you to Charlotte Holloway of Oxford University Press for her impeccable editorial assistance, and for remaining supportive throughout the whole process. I have worked on this book at various locations. The bulk of the research and the writing were accomplished mostly in London but also in Pretoria and Cairo. In July 2017 I spent two weeks in Alexandria that saw me through a particularly challenging stage in the book; I found patience and, ultimately, inspiration in the city’s coffeehouses by the Mediterranean. In December 2014 I spent one week in Coffee Bay
during South Africa’s bright summer. It was during my morning walks by the Indian ocean of the Wild Coast that the concept of the book as a whole finally came together.
I am grateful to my parents Nadia Abdelaziz and Mahmoud Abouelleil, and to my daughter Adele, for their encouragement and support. Finally, this book would not have happened without the philosophical acuity and moral support of my partner Rachel Bingham. Her influence on my thinking and my work has been profound.
Source Acknowledgments
Grateful acknowledgment is made to the authors and publishers of copyright material which appears in this book, and in particular to the following for permission to reprint material from the sources indicated:
The Guardian: extracts from Rachel Dolezal: “I wasn't identifying as black to upset people. I was being me,” December 13, 2015, Copyright Guardian News & Media Ltd 2018.
Jacks McNamara: extract from Navigating the Space between Brilliance and Madness: a Reader and Roadmap of Bipolar Worlds, The Icarus Project, www.theicarusproject.net.
Ohio State University Press: extract from Joel Myerson: Selected Letters of Nathaniel Hawthorne (OSU Press 2002).
Ken Paul Rosenthal: quotations from the documentary Crooked Beauty (2010), the first movie in the Mad Dance Mental Health Film Trilogy, www.kenpaulrosenthal.com.
Introduction xxvii
PART 1 Madness
1 Mental health activism and the demand for recognition 3
1.1 Introduction 3
1.2 A brief historical account of activism in mental health 4
1.2.1 Early advocacy and activism 4
1.2.2 1900s−1950s: “Mental hygiene” 6
1.2.3 1960s: The “antipsychiatrists” 7
1.2.4 The 1970s civil rights movements 8
1.2.5 Consumers/service users and survivors 10
1.2.6 Survivor identity 12
1.3 The meaning of madness 14
1.4 Mad Pride 17
1.4.1 Origins and activities 17
1.4.2 The discourses of Mad Pride 19
1.5 Philosophical engagement with Mad Pride discourse 25
1.6 Next steps 27
2 The problem of distress and disability 28
2.1 Introduction 28
2.2 Disability 30
2.2.1 Clarifying the criticism 30
2.2.2 Models of disability 31
2.2.3 Naturalism, normativism, and disability 34
2.2.4 Applying the social model to madness 37
2.2.5 Intelligibility and the limits of social accommodation 42
2.2.6 Political activism and the social subject 44
2.3 Distress 46
2.4 Conclusion 48
PART 2 Recognition
3 The concept of recognition and the problem of freedom 53
3.1 Introduction 53
3.2 What is it to be a free agent? Moral duty vs. ethical life 55
3.3 The conceptual structure of recognition in the Phenomenology of Spirit 58
3.3.1 The project of the Phenomenology 58
3.3.2 The concept of self-consciousness 61
3.3.3 The concept of recognition 65
3.4 What kind of concept is the concept of recognition? 67
3.4.1 Interpretations of Hegel’s idealism and implications for the concept of recognition 68
3.4.2 Recognition as affirmation of a normative status 71
3.5 What reasons do we have to accept the concept of recognition? 72
3.5.1 The dialectic of recognition and the meaning of necessity 72
3.5.2 Intuitions about self-conceptions 75
3.6 Conclusion 77
4 Identity and the psychological consequences of recognition 79
4.1 Introduction 79
4.2 Identity 80
4.2.1 A primer on identity 80
4.2.2 Identity and authenticity 84
4.2.3 The problem of essentialism 86
4.2.4 The relation between social identity and individual identity 88
4.3 The struggle for recognition 91
4.3.1 The motivation for recognition 91
4.3.2 The problem of ideology 93
4.4 Psychological consequences of recognition 95
4.4.1 Recognition and self-relations 96
4.4.2 Forms of recognition 97
4.4.3 Problems and implications of Axel Honneth’s account 101
4.5 Conclusion 102
5 Misrecognition: Political reform or reconciliation? 104
5.1 Introduction 104
5.2 Misrecognition as a social harm 105
5.3 Misrecognition and political reform 107
5.3.1 The theory of recognition as an ethical conception of the good 107
5.3.2 Two criticisms 109
5.3.3 Social justice and the limits of political reform 113
5.4 Misrecognition and reconciliation 114
5.4.1 The meaning of reconciliation 115
5.4.2 Why should we approach others with an attitude of reconciliation? 116
5.5 Responding to misrecognition: A role for political reform and reconciliation 120
5.6 Conclusion 122
PART 3 Routes to recognition
6 Mad culture 125
6.1 Introduction 125
6.2 What is culture? 125
6.3 Can madness constitute a culture? 127
6.4 Routes to cultural rights 130
6.4.1 Culture as a context of choice 131
6.4.2 The right to a culture or to my culture? 133
6.4.3 From culture to identity 135
6.5 Conclusion 136
7 Mad identity I: Controversial and failed identities 137
7.1 Introduction 137
7.2 The distinction between failed and controversial identities 139
7.2.1 Key features of identity 139
7.2.2 When things go wrong: On gaps in social validation 140
7.2.3 Method 142
7.3 Delusional identities 143
7.3.1 Clinical definitions and the criterion of sharedness 143
7.3.2 The President’s son 146
7.3.3 On being black when one is white 149
7.3.4 Communion with God 154
7.3.5 On being dead when one is alive 158
7.4 A methodology for distinguishing failed from controversial identities 159
7.5 Conclusion 162
8 Mad identity II: Unity and continuity of self 163
8.1 Introduction 163
8.2 (Dis)unity of self 164
8.2.1 Unity of self 164
8.2.2 Passivity phenomena 165
8.2.3 Ownership and authorship 167
8.2.4 Passivity phenomena and cultural psychology 168
8.2.5 Judgment of disunity: The role of context and activism 170
8.2.6 Conclusion 174
8.3 (Dis)continuity of self 174
8.3.1 Continuity of self 174
8.3.2 Spirit possession and dissociative identity disorder 177
8.3.3 Schizophrenia 178
8.3.4 Bipolar disorder 180
8.3.5 Overcoming discontinuity of self 182
8.4 Conclusion 182
9 Madness and the limits of recognition 184
9.1 Introduction 184
9.2 The limits of recognition 184
9.2.1 Extending the limits of recognition 186
9.2.2 Ordering madness 187
9.3 Narratives of madness 188
9.3.1 Subjective narratives 188
9.3.2 Professional narratives 188
9.3.3 Mad narratives 189
9.4 Overcoming impairments to identity formation 193
9.4.1 Overcoming discontinuity of self 193
9.4.2 Resolving disunity of self 195
9.5 Making the difference between subjective narratives and Mad narratives 196
9.6 Conclusion 198
PART 4 Approaches to Mad activism
10 Responding to the demand for recognition of Mad identity 203
10.1 Introduction 203
10.2 Normative force of demands for recognition (a précis of part II) 204
10.3 Does the demand for recognition of Mad identity possess normative force? 205
10.3.1 Trivial and morally objectionable identities 206
10.3.2 Irrational identities 207
10.4 Responding to misrecognition 215
10.4.1 What is the intended outcome? 215
10.4.2 Through what vehicle can this outcome be realized? 216
10.4.3 What attitude should inform these conversations? 216
10.4.4 What kind of activities can facilitate reconciliation? 217
10.5 Mad narratives and the cultural repertoire 218
