Madness

Justin Garson

Reviewed by Lisa Bortolotti

Madness: A Philosophical Exploration
Justin Garson
Oxford: Oxford University Press, 2022, £47.99
ISBN 9780197613832

I cannot remember the last time I read a book of philosophy that taught me something new and also took me on such a journey of images and sounds—a powerful reminder that, yes, rigorous philosophical ideas can be expressed in many forms, including excellent prose. Justin Garson’s Madness reads like a novel but instructs like an encyclopaedia. I revelled in an engaging narrative filled with suspense and cliff-hangers, where I challenged myself to anticipate the next twist: will my favourite philosopher be a strategist or a dysfunctionalist about madness? This was a journey of self-transformation and, as such, it was an often uncomfortable read: I have always thought of myself as someone who accepts a largely medicalized view of madness but is vocal about madness having meaning and purpose. While reading the book and for a long time afterwards, however, I became seriously concerned that I could not be both; that I had to choose. Ultimately, I have come to the conclusion that we can see madness as purposeful in a medical framework, although Garson may disagree.

In the introduction, Garson describes the point of the book in terms of ‘extracting a certain vision’ of madness: madness not as a defect but as ‘a goal-driven process, a well-oiled machine, one in which all of the components work exactly as they ought’. The contrast is between madness-as-strategy (‘in the mad, a purpose is being fulfilled’) and madness-as-dysfunction (‘when someone is mad, it is because something has gone wrong inside of that person’). This polarity is beautiful in its simplicity but it transpires as a fiction over the course of the book, as Garson masterfully proves that the two visions collide and combine in multiple ways, to the point that it is difficult to tell whether any statement about madness is an endorsement of strategy or dysfunction.

Garson’s project is itself one of contrasts. The teleological mode of interpretation of madness (madness-as-strategy) has always been there, but it has been buried; the book is described as ‘an exercise in concept building’, but none of the concepts are new. The book indeed shows that the idea of madness-as-strategy has always been an option—not always the dominant or the only approach, but certainly an available approach. To my mind, the book does more and does less than building concepts: it does more because it endorses and passionately defends, rather than merely explicating, the vision that emerges when the right concepts are combined; and it does less because these concepts already exist and need not be built ex novo. Mostly what the book does is create an irresistible thread, establishing a connection between different versions of the same core idea.

One difficulty in grasping the scope of this analysis is that the buzz words are left buzzing. If madness is a strategy, what is a strategy for, exactly? If madness is a dysfunction, which are the dysfunctional processes? But the reason for this vagueness becomes apparent over the course of the book: each point in time, each historical and cultural context, offers different answers to such questions, until the only thing that persists is this sense of purpose on the one hand, and this sense of failure on the other.

Garson is explicit about the four benefits of his ‘recovery operation’: We gain new tools for the historian as we go beyond interpretations of madness that rely on the tension between dualism and physicalism. We acquire a new lens through which we can appreciate the debates about madness and disorder in the philosophy of psychiatry as we move to a deeper level of analysis than that necessary for understanding challenges to medicalization. We develop a new logic of intervention as we start conceiving of treatment not as an elimination of harmful symptoms, but as a recognition of symptoms as adaptive responses to a crisis. And we are also gifted a new foundation for mad activism that views madness not as a pathology or a defect, but as a positive identity and ‘the default state of humankind, ground zero of the conscious mind’ (p. 12).

In Part 1, Garson argues that it is a mistake to view the contraposition between Hippocrates and the alternative conceptions of healing as a version of the contemporary distinction between naturalism and anti-naturalism. Rather, we should read their disagreement in terms of Hippocrates proposing a view of disease as dysfunction, and his opponents endorsing instead a view of disease as teleology. Garson defends the view that Hippocrates and his followers did not exclude the divine from medicine, but wanted to separate religion (which they thought relevant) from magic (which they despised as a form of superstition). Nonetheless, some magical and superstitious thinking remains in Hippocrates’ writings, highlighting a difficulty for any naturalist interpretation of his thought. For Garson, Hippocrates’ legacy is seeing disease as a negation of teleology: medicine ‘restores the creature’s capacity to attain its good’ (p. 25).

Then, Garson offers a beautiful reconstruction of how, after the advent of Christianity, madness was viewed as an instrument of punishment and redemption. Magicians and conjurors are replaced by exorcists and witch-hunters as proponents of the purposive nature of madness. Garson claims that there is no transmission of knowledge from the former to the latter (no lineage); the idea simply resurfaces. The Christianization of medicine is characterized by a change in the way gods relate to humans. Whereas the Greek gods did not care much, the Christian god is concerned about our moral worth. This is where punishment and redemption come from, from the concern of god for us.

An interesting discussion of the scope of medicine ensues. How much responsibility and authority do physicians have in this picture? God intervenes, but not on the individual’s circumstances. He created reality in such a way that if one misbehaves, one gets punished; and if one suffers, by doing so one redeems oneself (‘if you overindulge in food or drink, you get sick’, as Garson puts it; p. 41). This means that there is still some room for the physician: we can ask what god is punishing a person for, but also what natural mechanisms connect the person’s sin with their disease. In the Anatomy of Melancholy (1621), Robert Burton develops a notion of madness as misuse, where madness is due to irresponsibility: people are mad when they misuse their god-given faculties and the blame is on them, not god. Bad behaviour is at the origin of this: ‘disposition becomes habit’ and ‘habit, so fixed, is itself a form of madness’ (p. 51). Garson also discusses George Cheyne’s work on melancholy in The English Malady (1733) . Melancholy is a dissatisfaction with what god gave us, a punishment for sin that we deserve, but it also enables us to reform. Redemption requires a change of moral character. A legitimate question is why god does not make us good to start with, and the answer is that he wants us to be free to choose, to err and to mend. Madness is as much a cure as it is a disease: it enables god to punish and purify us without taking away our free will.

In Part 2, Garson explores the crystallization of madness-as-dysfunction as the dominant view: by the eighteenth century ‘madness is mere pathology’ (p. 75), and when someone is mad it means that something is wrong inside them. This differs from the Hippocratic approach in the classification and enumeration of forms of madness according to the faculties of the human mind, a persistent tendency that Garson attributes to Kant. Kant makes a good start with this project of classification and enumeration in his Essay on the Maladies of the Head (1764), where he makes some distinctions between derangement as an aberration of experience, dementia as an aberration of judgement, and insanity as an aberration of reason. But, importantly, Kant also concedes that there is method in madness and that even the ‘unhinged mind’ is arranged into a system rather than being in a state of pure chaos. For Kant, the healer’s job is to identify which faculty of the mad person’s mind has stopped working properly. Madness is objectified and hides a secret to be discovered, and this discovery is the healer’s task, a task to which the mad person cannot and should not contribute. The mad person’s speech is the result of their madness, not something meaningful in its own right.

The rest of the discussion in this part is an examination of the relationship between madness and reason offered by various other influential authors. Locke’s perspective on madness differs from that of Kant: Locke’s assumption is not that the mental faculties are operating badly, but that they have defective material on which to operate. The mad person does not lack reason, but makes valid inferences from flawed premises. For John Haslam in Bedlam hospital, the mad person rejects reason, but needs to pretend to use reason. So, there is a sort of dissimulation of reason, a form of other-deception, in which the mad person is proficient. But for Arthur Ladbroke Wigan, author of A New View of Insanity (1844), the dissimulation is a form of self-deception made possible by the dual nature of the mind: madness as a ‘deliberate diversion from the unremitting tragedy of everyday life’ (p. 125). This understanding of madness as a coping strategy is first found in Johann Heinroth’s Textbook on the Disorders of the Soul (1818), where he argues that some forms of madness can be a response to trauma. Madness constructs a fiction because reality is unbearable: imagination is allowed to take precedence and create a reality that is preferable for the person. In the eighteenth and nineteenth century, Philippe Pinel and Wilhelm Griesinger seemed to agree with Kant that madness is due to a faculty of the mind breaking down, but they also recognized that some forms of madness have a healing function. This view of madness as a fix is applied to delusions in particular, where what the person desires comes true: delusions fulfil the mad person’s wishes. The project in Emil Kraepelin’s Clinical Psychiatry: A Textbook for Students and Physicians (1902) is described by Garson as the ‘biologization of Kant’, is the author who most consistently exemplifies the madness-as-dysfunction approach, excluding purposiveness and goal-directedness from all instances of genuine madness.

Part 3 focuses on madness and evolution, and takes us from Freud to the present day. In The Interpretation of Dreams, Freud views all forms of madness as functional by introducing the ‘teleology of the unconscious wish’, but there is still a sense in which madness can be a failure. Madness may provide a strategy that does not succeed in fulfilling its goals. More recently, stories of madness as an adaptation take centre stage, and Garson observes how the clash between the dysfunction view and the product-of-evolution view of madness has been largely ignored. This part of the book is as worthy of attention as the previous two, but covers better known material, so I will not describe it in detail here. It will suffice to say that Chapter 14 offers an excellent description of the principles behind the DSM.

The magic of Garson’s book is that it shows that conflicting conceptions of madness can co-exist in the same historical period, in the same philosophy, even in the same thinker. Maybe this tells us something: madness-as-dysfunction and madness-as-strategy are two sides of the same coin. Madness is a strategy in that it serves an important end; but it is sub-optimal as a strategy, because it does not wholeheartedly promote the well-being and agency of the mad person. This idea has been advanced in the recent philosophical literature on delusions that Garson knows so well—most notably in work by Ryan McKay and Daniel Dennett ([2009]), where they discuss the possibility that some delusions are adaptive misbeliefs, and in my work on epistemic innocence (Bortolotti [2020]), where I speculate that delusions may offer not just psychological relief from a state of uncertainty but also some opportunities for the person to exercise their epistemic agency in a time of crisis. There is an interesting comparison to be drawn here: in these contemporary and partial renditions of the madness-as-strategy vision, madness is just one of the many ways in which big and little irrationalities support our agency, just as in Medieval times, madness was one of the means available to god to bring about our moral reformation.

It is also interesting that recent attempts at seeing madness as purposeful recognize that the big and little irrationalities we learn to live with, the same irrationalities that can support our agency and help us thrive, are not dysfunctions. They are not deficits, faults, pathologies, glitches. They can become part of a problem, but they begin as imperfect responses to crises. A good illustration of this are the ‘insight paradox’ stories (Belvederi Murri et al. [2016]): it may be surprising to hear that people can become unwell, severely depressed and suicidal, when they start gaining insight into their delusions. But if delusions are a coping mechanism to help people overcome an extremely difficult time, then this should not be surprising. ‘Curing’ people of their delusions means taking away the only response they have to what Garson aptly calls the ‘unremitting tragedy of everyday life’, leaving nothing in their place. Some irrationalities can kill us and some can rescue us, and those that can kill us at one time can rescue us at another. There is no broken mechanism inside us; rather, there is a world collapsing around us and we constantly adapt to face it. That does not mean that we do not need help when we are in the line of fire, and it is a great merit of Garson’s nuanced account that he never indulges in the easy step from madness-as-strategy to the rejection of the role of medicine in providing some means of support. There does not need to be a dysfunction for us to receive medical support, as we turn to medical professionals in pregnancy and when our lifestyles do not serve us well—when we eat too much or sleep too little. Similarly, we may need medical support as mad persons.

As promised, Garson’s reconstruction of the two visions of madness successfully provides new resources and inspiration for historians, philosophers of psychiatry, and clinicians. However, I am not so sure how consistent it is with mad activism, the movement for which Garson intends to provide ‘intellectual scaffolding’. For the most part, the madness-as-strategy vision as reconstructed by Garson does not sit comfortably with madness as a positive identity and as a force of political change and resistance. In the history of madness-as-strategy that Garson reconstructs, madness is not the means by which we can pursue the goals with which we identify; it is the means by which we are made to chase an inscrutable end—almost an explicit negation of our capacity to shape our own lives according to our values. When madness is seen as a strategy, it is not our own strategy, but the actualization of some obscure plan that we do not fully understand. It’s the strategy of a god who punishes before redeeming and maybe saves, but who has little compassion for our struggles. It is the strategy of the homuncular, divided mind that drives us to escape reality for a world of illusions and dreams, and leaves us somewhere in between. It is the ‘strategy’ of natural selection, which ‘wants’ us all well fed and well rested until we bear fruit, but does not care about how authentic and fulfilling our lives are. The hope is that a new version of the madness-as-strategy account will emerge and lead us into a future where the coping mechanisms we adopt are more robustly under our control.

Lisa Bortolotti
University of Birmingham
l.bortolotti@bham.ac.uk

References

Belvederi Murri, M., Amore, M., Calcagno, P., Respino, M., Marozzi, V., Masotti, M., Bugliani, M., Innamorati, M., Pompili, M., Galderisi, S. and Maj, M. [2016]: ‘The “Insight Paradox” in Schizophrenia: Magnitude, Moderators, and Mediators of the Association between Insight and Depression’, Schizophrenia Bulletin, 42, pp. 1225–33.

Bortolotti L. [2020]: The Epistemic Innocence of Irrational Beliefs, Oxford: Oxford University Press.

McKay, R. T. and Dennett, D. C. [2009]: ‘The Evolution of Misbelief’, Behavioral and Brain Sciences, 32, pp. 493–510.