Précis of Madness: A Philosophical Exploration

I see Madness less as a monograph, complete with a proper thesis and argument structure, and more as a series of conceptual exercises. Its goal is neither to instruct the reader about the intellectual history of psychiatry nor to demonstrate a philosophical thesis about the nature of mental illness. Rather, it aims to induce a certain perspective shift in the reader. Hence the book’s warning: “There is no synopsis or abbreviation or précis that can possibly serve as a substitute for reading the book”. (Garson 2022, 6) It’s more like a machine that either does its job or fails to work the way it should.

The somewhat peculiar aim of the book also problematizes the very idea of a book symposium. As traditionally understood, a book symposium consists of a series of critiques alongside an extended defense. (It’s notable that book symposia are sometimes called “author-meets-critics” sessions.) Such symposia evoke the idea of an author confronted, face-to-face as it were, by a series of open-minded but skeptical readers, readers who are prepared to indicate the ways in which the book falls short of its promise, by, say, exposing fallacious arguments or highlighting unacknowledged alternatives. As the book is less of a monograph than a machine, it imposes a different set of questions on the symposiast—not Did Garson convince me of his thesis? but Is the book a good tool? Are there better tools for the job? Is it a worthwhile job in the first place?

With those qualifications in mind, however—and given the book’s explicit rejection of the idea that it could be encapsulated by a précis—I will describe as briefly as possible the purpose of the tool, the manner of its operation, and the benefits of its deployment.

Here are some background beliefs that I hold. The history of psychiatry, or better, the history of madness, can be seen as a clash or confrontation between two major paradigms or worldviews. Most major theorists of madness can be comfortably seen as accepting one or the other of these systems, and most of the major disputes and paradigm shifts in the study of madness can be usefully viewed through this lens. The clash that I envision, however, is not equivalent to any of the clashes that we are used to hearing about, such as that between biological and psychological worldviews or that between reductionistic and holistic worldviews. Rather, it is between dysfunction-centered and function-centered worldviews, or what I call madness-as-dysfunction and madness-as-strategy.

Madness-as-dysfunction and madness-as-strategy are not meant to describe theories about madness; they are meant to describe psychological tendencies on the part of researchers, tendencies to “approach” madness in a certain way. The core idea behind madness-as-dysfunction is that when somebody is mad (construed broadly to include things like extreme low mood, panic attacks, hearing malicious voices, having strange beliefs that other people don’t accept, being such a “difficult person” that it’s hard to hold down a job, and so on), it’s because something inside of them, in their mind or brain, is not working the way it is supposed to. Seen this way, madness (or its various expressions: malicious voices, low mood, etc.) is seen as a “symptom” of a “disorder”. It is the kind of thing you might see a doctor to diagnose and treat, perhaps with medication or therapy.

(But wait a minute, you’ve just described psychiatry itself! Exactly—my point is that madness-as-dysfunction has become so entrenched in psychiatric thought that it’s difficult to recognize as a distinct paradigm, one that could have been different, rather than just “business as usual”.)

There is, however, a second paradigm, one that once held a much stronger foothold in the field but that has been largely stamped out, with remnants existing here and there like smoldering fires across a barren landscape. I call it madness-as-strategy. The core idea here is that when somebody is mad, everything inside of them is functioning exactly as it is supposed to, or as it ought, or as nature intended.

With this background set of beliefs, the purpose of the book—the job that it is meant to do—is not, in the first place, to demonstrate that this is an intellectually useful distinction. Rather, it is to dislodge the reigning worldview, madness-as-dysfunction. That’s why I say the book could be read as a series of conceptual exercises designed to reveal madness-as-dysfunction as a distinctive and historically specific worldview, rather than the silent default of all theorizing. It is to lure madness-as-dysfunction out of its hiding place and expose it for what it is by contrasting it with an equally plausible but opposing alternative: madness-as-strategy. Crucially, as I emphasize in the book

The question is not one of destroying madness-as-dysfunction or refusing to apply it where it deserves to be applied, but to make it possible to even raise the question of whether madness-as-dysfunction ought to be applied in any particular case. (Garson 2022, 2)

I’ll close this synopsis by briefly outlining four main benefits of the book: for history, philosophy, Mad Pride, and mental health care.

First, the book provides a new set of tools to the historian to help them create new narratives about the history of madness—narratives that go beyond viewing this history merely as a clash between biological and psychological points of view, or even as a pendulum that swings back and forth between them. Incidentally, I do not accept what is sometimes described as the “biopsychosocial” point of view because it remains firmly within a certain controlling narrative that I would like to challenge, namely, that psychiatry’s history is best viewed as a clash between biological and psychological perspectives. I return to this theme in my response to Khalidi.

Second, the book provides a new set of tools to the philosopher. Madness-as-dysfunction has become so entrenched in our current mental health landscape that it is often difficult to see as a distinctive worldview, one consolidated for fairly arbitrary (political, social, economic) reasons. One mark of its entrenchment is that philosophical definitions of the very concept of mental disorder or mental illness often rely on the concept of dysfunction, as if it were a necessary condition of what it is to be mad, as if the concept of dysfunction is “analytically contained” in the concept of mental illness. Wakefield (1992), for example, famously defined “mental disorder” in terms of harmful dysfunction, and Boorse (1977) defined “disease”, whether mental or physical, in terms of the reduction of functional ability below typical efficiency.

The following point is crucial: I do not reject the Wakefieldian definition of mental disorder. I think Wakefield gives us the clearest and most philosophically defensible articulation of our current widely accepted notion of mental disorder. Moreover, I tend to agree with him that the content of the concept of mental disorder, as it exists today, is, roughly, the following: a harmful psychological condition caused by an inner dysfunction (e.g., Wakefield et al. 2006). However, if it turns out, as I suspect it will, that many of the psychological conditions that we currently refer to as “mental disorders” are, in fact, functional rather than dysfunctional, then that would give us a good reason to stop calling them “mental disorders”—and perhaps, in time, to abandon the category altogether.

The third benefit is that the book provides intellectual scaffolding for the movement known as Mad Pride or mad advocacy. “Mad Pride” is modeled on other progressive social movements, such as Black Pride or Gay Pride. It seeks to take an identity—in this case, being mad—that has often been disparaged or denigrated, and present it in a more positive light, and as a potential seat of political solidarity. Clearly, a crucial step in getting Mad Pride off the ground is to reject models that depict madness as merely a disease—a “condition” for doctors to “cure”. Simply put, it requires a way to intellectually displace dysfunction-centered framings from their centrality in the mental health landscape. Madness-as-strategy does just this.

The fourth benefit, which I now see as the most crucial, has to do with changing the landscape of mental health care. (I would say “treatment”, so long as the word is not taken to imply that madness or its various expressions are diseases to be cured, but forms of life that often require thoughtful support or empowerment.) I am inclined to believe that the entrenchment of madness-as-dysfunction in our current mental health landscape does a profound disservice to people who suffer with very real and debilitating problems, or in some cases, to people who possess cognitive styles that are marginalized or misunderstood, such as ADHD, autism, or dyslexia, conditions often presented under the banner of neurodiversity.

Take, for example, depression. If we see depression, as I think we should, as functional rather than dysfunctional—as, say, the brain’s evolved signal that something in the environment is not going well rather than a “chemical imbalance”—this perspective utterly transforms the question of treatment. Quite simply, it means we ought to spend more time listening to what it’s trying to say, rather than bombarding it with powerful psychoactive medications. (Of course, there are nuanced questions about when and under what conditions drugs might be useful for navigating mental health challenges, questions that I address in detail in Garson forthcoming a).

There is only one major respect in which my point of view has shifted since I wrote the book. I once envisioned the book as a plea to psychiatry to become more inclusive and pluralistic, as if I were encouraging psychiatrists along the following lines: “There are dysfunction-centered framings of mental health problems, and there are function-centered framings, and it would be good to have an open mind about this kind of thing. Perhaps some kinds of mental health problems, for some people, are best seen as dysfunctions, and others, as functions”. But I have come to believe that psychiatry, in its inmost essence, is wedded to a dysfunction-centered framework (Garson forthcoming b). After all, psychiatry is a branch of medicine, and the goal of medicine is to treat or prevent diseases. To abandon a dysfunction-centered framing, then, is to cease practicing psychiatry. That is why I now think that mental health problems that are functional rather than dysfunctional do not in fact fall under the jurisdiction of psychiatry. For those, we must go beyond psychiatry. But that is a topic for another book.