Mad studies

At AMS this year a friend told me about an academic subspecialty I hadn’t heard of before, “mad studies.”* Mad studies is the offspring of disability studies and seeks to draw the sting from invidious words like “mad” just as its parent field does with “cripple.” As with all the various “studies,” mad studies is the academic wing of a social-justice movement (in this case, “mad pride”). And the bottom-line action of any such movement is to identify a majority stigma against a minority, raise consciousness among the people who have borne the burden of the stigma, and organize them into a community that understands itself as such. In this way, the source of the stigma — disability, ethnicity, religion, etc. — is revalued and becomes the basis for an identity. “Black is beautiful,” “sisterhood is powerful.” And perhaps now madness becomes insight. Academic minority studies try to analyze the ways stigma works in society and to theorize the identities of those who have suffered from it.

But is mental disorder an illness or an identity?

Andrew Dell’Antonio raised the issue when I wrote a piece on depression a few months ago. In the comments, Andrew linked to a piece by Nick Walker that prods us to rethink our attitudes towards Autism. And by “our” attitudes I mean those of the neurotypical population who almost invariably think of Autism as a pathology: you “have” Autism, or “suffer” from it. Yet do we say that gay people “suffer from homosexuality?” This is what Walker asks, and it’s a fair question. No, we don’t. The implication of this phrasing — that being gay is some kind of disease — is offensive. So Walker asks that we move from the “pathology paradigm,” in which we relate to Autism mostly as an illness, to the “neurodiversity paradigm.” The latter implies three things: that there is no single true model of mental functioning; that diversity in types of mental functioning is something to celebrate; and finally that

The social dynamics that manifest in regard to neurodiversity are similar to the social dynamics that manifest in regard to other forms of human diversity (e.g., diversity of race, culture, gender, or sexual orientation). These dynamics include the dynamics of social power relations – the dynamics of social inequality, privilege, and oppression – as well as the dynamics by which diversity, when embraced, acts as a source of creative potential within a group or society.

And here we can see the characteristic move of every pride-and-identity movement: the stigma is reversed, shame becomes pride, the burden is lifted, and those who were alone find their voice as a community.

So it’s reasonable to ask whether it wasn’t a mistake for me to call depression a “mental illness,“going so far as to compare it to diabetes. And I don’t have a consistent answer.

My first reaction is, suicide from untreated depression kills a lot of people — tens of thousands per year in the U.S.** I know people who would be dead without their medications. Past a certain point, the idea that mental disorder is insight or liberation, that we should throw our medications away and storm out of our therapists’ offices and march into the street singing “We Are Family,” is destructive nonsense.

And yet I have learned things from depression that I would not have learned otherwise: how to listen a bit better to people; how to understand better what other people are going through; finding the limits of my own strength; discovering the limitations of my pride and will; learning how to ask for and accept help. Depression is the harshest of all masters; learning from depression is like “The Cruel Tutelage of Pai Mei.”

cruel tutelage

There is some truth in what James Hillman says: “through depression we enter depths and in depths find soul. Depression is essential to the tragic sense of life. It moistens the dry soul, and dries the wet. It brings refuge, limitation, focus, gravity, weight, and humble powerlessness.” (James Hillman, Re-Visioning Psychology, 99.)

But then, on the other hand, most people learn exactly the wrong lessons from depression — for example, that you’re a piece of shit and should die. Depression can ruin your health, lose you your friends, destroy your family, lay waste to everything you have ever tried to accomplish, and leave you dangling from a rope’s end. If there’s a medical treatment that will stop all that from happening, why would you not accept it? Because embracing neurodiversity “acts as a source of creative potential within a group or society?” It seems as if that deal works out better for those who propound abstract social-justice doctrines than it does for people who are simply suffering from depression.

But on yet another hand, though, yes, there are clearly problems with the pathology paradigm. To explain what they are, I need to get a little abstract.

Let’s start with a very, very large historical phenomenon: secular modernity, a.k.a. modernization, a.k.a. post-Enlightenment instrumental rationality. We’re talking about the philosophical operating system that runs in the head of almost every person living in the North Atlantic world and increasingly everywhere else. Calling it “philosophical” is a bit misleading, actually, because the assumptions of secular modernity operate on a pre-philosophical, pre-reflective level. Modernity isn’t something we think, for the most part; it’s something that allows us to think what we think. The pathology paradigm plays out on this level.

Secular modernity denatures conventional moral categories: if “evil” is the shadow cast by God, when we do away with God we are left explaining wrong actions solely within what Charles Taylor (in A Secular Age) calls the “immanent frame,” which here means explaining them as bad functioning of the organism. Everything becomes an illness. If mind is reduced entirely to brain (as it must be, under the ruling materialist dispensation), then mind as such disappears and what is left is solely the behavioral manifestation of disordered machinery. Motivations, tastes, ideas, loves, angers, fears . . . all this internal subjective stuff, the stuff of mind, boils away.

All the better to classify you with, my dears. The impulse behind understanding human wrongness is no longer moral/religious (wrongness as sin) nor even humanistic (wrongness as a legible trace of biography or social existence), but scientific, an effort to grasp the exact limits and forms of wrongness as such, wrongness in its most objective aspect, as an autonomous thing separate from human subjectivity. This means grasping all wrongness as bad functioning, as pathological behavior. When this move is made, all our various wrongnesses can become pathologies, and they now can be ordered in the rows and columns of a typology.

Thus we have the ever-expanding Diagnostic and Statistical Manual (DSM), now in its fifth edition. Sam Kriss wrote a scalding, bitterly funny satire of the DSM-5 for The New Inquiry that pretends the book is actually a brilliant dystopian novel with characters (“figures comparable to the cacophony of voices in The Waste Land or the anonymously universal figures of Jose Saramago’s Blindness“), a setting (though an abstract and conceptual one), and a prologue to introduce us to it:

The scene this prologue sets is one of a profoundly bleak view of human beings; one in which we hobble across an empty field, crippled by blind and mechanical forces whose workings are entirely beyond any understanding. This vision of humanity’s predicament has echoes of Samuel Beckett at some of his more nihilistic moments—except that Beckett allows his tramps to speak for themselves, and when they do they’re often quite cheerful. The sufferers of DSM-5, meanwhile, have no voice; they’re only interrogated by a pitiless system of categorizations with no ability to speak back. As you read, you slowly grow aware that the book’s real object of fascination isn’t the various sicknesses described in its pages, but the sickness inherent in their arrangement.

The crux of Kriss’s review is his suggestion that the scientific mania for classification and objective assessment is itself just that, a mania, an arch-sickness or meta-sickness that generates the teeming and ever-proliferating sicknesses of the DSM-5.

The idea emerges that every person’s illness is somehow their own fault, that it comes from nowhere but themselves: their genes, their addictions, and their inherent human insufficiency. We enter a strange shadow-world where for someone to engage in prostitution isn’t the result of intersecting environmental factors (gender relations, economic class, family and social relationships) but a symptom of “conduct disorder,” along with “lying, truancy, [and] running away.” A mad person is like a faulty machine. The pseudo-objective gaze only sees what they do, rather than what they think or how they feel. A person who shits on the kitchen floor because it gives them erotic pleasure and a person who shits on the kitchen floor to ward off the demons living in the cupboard are both shunted into the diagnostic category of encopresis. It’s not just that their thought-process don’t matter, it’s as if they don’t exist. The human being is a web of flesh spun over a void.

“The human being is a web of flesh spun over a void” — I have never read a sentence that better sums up what our understanding of human beings, human life, human culture and society and history, is reduced to when our education is dictated by the philosophical assumptions of scientific materialism. Though I shouldn’t pick on scientific culture too much: this same sentence could as easily come from a post-Nietzschean, neo-Marxian, vaguely-Foucauldian, H-P-Lovecraftian, anti-humanist humanities academic of the sort that represents the intellectual current Charles Taylor calls “immanent counter-Enlightenment.” Both strands of modern thought, though apparently opposed, have a lot in common, not least a desire to purge all metaphysics from our idea of the human. (I have elsewhere argued that this is doomed to failure, though the attempt results in some interesting forms of unavowed metaphysics, of which more below.)

Back to the pathology paradigm: when we call “depression” what at other times has been called “melancholia,” we might be acceding in advance to an agenda of a “strangely causal word.” So Andrew Solomon calls the word “depression,” a medicalized notion of the thing itself and loaded with all its web-of-flesh-spun-over-the-void metaphysical baggage. But the real ding an sich, the Black Dog that stalks through the lives of 350 million people worldwide, is nothing new, has no clear lines of causality, and has never been something to trifle with:

I use depression here to describe states for which we would now use that term. It is fashionable to look at depression as a modern complaint, and this is a gross error. As Samuel Beckett once observed, “The tears of the world are a constant quality.” The shape and detail of depression have gone through a thousand cartwheels, and the treatment of depression has alternated between the ridiculous and the sublime, but the excessive sleeping, inadequate eating, suicidality, withdrawal from social interaction, and relentless despair are all as old as the hill tribes, if not as old as the hills. In the years since man achieved the capacity for self-reference, shame has come and gone; treatments for bodily complaints have alternated and crossed with treatments for spiritual ones; pleas to external gods have echoed pleas to internal demons. To understand the history of depression is to understand the invention of the human being as we now know and are him. Our Prozac-popping, cognitively focused, semi-alienated postmodernity is only a stage in the ongoing understanding and control of mood and character. [Andrew Solomon, The Noonday Demon: An Atlas of Depression, 286.]

So which of these approaches is the right one? Prayers? Prozac? How about the one I identified at the beginning of this piece — making mental disorder an “identity” and the basis for some sort of politically-empowered community?

There is a value to seeing yourself as a part of a community, of knowing that you are not alone; I said as much in my previous post on depression. I sense that community when I talk to those of my friends who share my experiences with depression. But I don’t find the pride-and-identity approach any more likely to grasp the whole truth than anything else. The neurodiversity paradigm, whatever its merits, is as historical and time-bound as the pathology paradigm. That’s not a knock against it, exactly, but let’s not pretend we have won our way to truth at last. We have won our way to another face of a truth that can reveal itself only in time, reveal itself as one in a series of such revelations whose full unfolding might take fully as long as our species has to run its course. Solomon, again: “To understand the history of depression is to understand the invention of the human being as we now know and are him.”

What lies behind the postmodern fetish for new and liberating identities is, again, modernity.*** It is only a commonplace to say that the great hallmark of modernity is disenchantment, the progressive subtraction of power and agency from things in the universe — first God, then art (who among the clever set wants anymore to say that particular artworks are beautiful or powerful all on their own?), and then, finally, human beings are evacuated of any numinal sense of power and potentiality. In the blighted world of the DSM-5, humans are puppets on the string of their disorders; in the postmodern academy, they are puppets of social and economic and political forces.

Where, then, can we find meaning? Where can we place our faith? Is there redemption anywhere? For the scientist, there is redemption in science. The negation of meaning is itself the meaning. Meanwhile, the last thing anti-humanist academic postmoderns (AHAPs for short) want to talk about is redemption. But while AHAPs might be suspicious or scornful of humanism, they regrettably cannot avoid being human. For all their brave Nietzschean talk, they can’t live in hopelessness any better than anyone else. Where they put their faith is in politics.

To be sure, our actual political options may give us little to choose from and little to hope for. In our lived experience, politics is a savage and venal enterprise. But for the AHAP, it’s always “next year in Jerusalem.” Things are irredeemable now, but some day . . . it’s uncool to finish that sentence, though. We don’t want to come out and say what we think or hope will happen some day. But by god we will work for that some day that we pretend not to believe in. And if we cannot bring ourselves to believe in any real-world politics, present or future, we can put our faith in a more abstract and theological category, the political. Thus we will insist that all issues of culture are in the end political issues and assimilate all present concerns to the political horizon.

And if we no longer believe in a Utopian future state, then we can believe in a present made meaningful by the shadow that the future, however unwinnable in fact, casts over it. No wonder Theodor Adorno has become the patron saint of contemporary humanities academia: he strikes the only redemptive pose that fully modernized intellectuals can permit themselves, negation as redemption.**** Which you will notice is very close to what I said about science: the negation of the meaning is the meaning. The intellectual is to be like Moses, forever at the borders of the promised land, able to see it but never to claim it. As Adorno writes at the end of Minima Moralia, “The more passionately thought denies its conditionality for the sake of the unconditional, the more unconsciously, and so calamitously, it is delivered up to the world. Even its own impossibility it must at last comprehend for the sake of the possible. But beside the demand thus placed on thought, the question of the reality or unreality of redemption itself hardly matters.” [Adorno, Minima Moralia, trans. E. F. N. Jephcott (London:Verso) 247.] It wouldn’t surprise me if someone had gotten a tattoo of that passage.

adorno tatt

Writer Carey Harrison with the first page of Minima Moralia tattooed on his back. If that doesn’t demonstrate quasi-religious devotion I don’t know what does.

So when I hear someone suggesting that the politicization of mental illness (or whatever we’re calling it) and formation of “the mad community” will do the trick, color me skeptical. It just seems like the kind of thing we would say. It’s the kind of thing that will seem as quaint to our descendants as the idea of treating madness by exorcising demons now seems to us. (Not that I don’t see some value in demonology, either . . .)

So do I think depression is a mental illness? Sure, when it suits. Sometimes that’s how it plays out. The great advantage of the “pathology paradigm” is that makes mental disorders no-one’s fault.***** It makes it easier to come in from the cold. It suggests a course of treatment; the normative approach is one of consistent and watchful care, and that is a whole lot better than the usual alternative, which is nothing. Is it a spiritual condition? Sure, sometimes. Is it a part of who you are? Yes, actually, it is, or can be. Should you try to get rid of it, then? Well, that’s not a bad idea. But is it always a curse? There’s no curse without its blessing, friendo. And no blessing without its curse. Is it all a mystery, a mess, a farrago of contradictory notions, a scramble suit of ever-shifting appearances that settle into no one fixed identity? Why yes, yes it is. There at last is a statement I can get behind.

scramble suit

Depression is a mystery because humans are a mystery, and every time we try to foreclose the mystery with some appealingly unified explanation (“it’s an illness,” “no, it’s an identity,” “no, it’s a spiritual trial” etc.) we are doing that human thing of insisting on one single cause and, so doing, disrespecting our human condition, of which it seems truest to say that its nature is never just one.

*There is a recent edited anthology in this field, Mad Matters: A Critical Reader in Canadian Mad Studies. (For whatever reason, this field is heavily represented by Canadians.) For an overview of the book and mad studies more generally, see Mark Castrodale’s review of this book.

**In 2013, the number of suicides in the U.S. was 41149, and at least half of them are directly attributable to depression. The two links I’ve provided here are full of dismaying statistics; if you are one of those people who likes to think that depression is a fake concept and that depressed people are self-dramatizing weaklings, I suggest you look at them.

***I never for a second believed that “postmodernism” was anything but a strain of modernism, but that’s an argument for another day.

****If my characterization of Adorno as an academic saint seems over-the-top to you, consider this artwork I saw at the Minneapolis Institute of Arts, called (so far as I could tell without a trace of irony) “Saint Adorno“:

https://i1.wp.com/archive.artsmia.org/until-now/artworks/artwork_large/armajani_exile.jpg

Don’t get me wrong, I quite like this piece, especially its riffing on Giacometti’s The Palace at 4 a.m. I don’t even have a problem with investing Adorno with a certain modern kind of sanctity. He was an admirable thinker and an admirable man, and I know scholars, like my friend Jim Buhler, who make our profession better by embodying the very high ideals that Adorno represents. But I would like scholars to recognize that their intellectual commitments are not purely intellectual, as we always like to think, but at least partly religious.

*****I disagree a little with Kriss when he suggests that pathologization makes “every person’s illness … somehow their own fault” — in the neoliberal state it becomes your own problem, but that’s not quite the same thing.

About Phil Ford

Chairman of the Committee for the Memorial to the Victims of Modernism
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5 Responses to Mad studies

  1. David A. Powers says:

    From the perspective of someone who suffers from bipolar type II:

    * I don’t experience bipolar as an illness.

    * Industrial medicine is big business. It is good at producing chemical interventions, which scale and can be mass-produced, and it has a strong incentive to produce these interventions for every conceivable problem in the hopes of making a profit. Furthermore, if pills are being produced to solve a problem, that problem will INEVITABLY be viewed as an illness, because the discourse of pathology is the only available discourse within the realm of industrial medicine.

    * The terminology of pathology tends to reduce patient subjectivity; patients become objects who are subjected to treatments defined by professionals: it is the professionals who are the subjects and actors in typical treatment scenarios. This is problematic for non-chemical interventions, which depend on self-efficacy and the ability to make hard choices and take control of your life.

    * I deal with my problematic mood tendencies via non-chemical means. This is a complex balancing act, because once the mood swings are really in full it may be too late; so the intervention actually must occur while one is experiencing a normal mood. The biggest danger of bipolar, for me, is that hypomania is addictive. I can bring it on purposely, and I can use it to do things like writing code for 24 hours straight. After that, I will experience an extreme, horrible crash that can push me into very dark places. The important thing here is that at every step, my individual choices make ALL THE DIFFERENCE as to the quality of life I have. It is not up to a doctor, or a pill, it’s up to me to make healthy choices. I don’t always have this choice: once the mood swing is under way, the amount of choice I have becomes limited. During those periods, it’s reasonable to look at myself as really “sick”. But most of the time, “sick” is only a potential, and my own choices will dictate whether I experience that potential or not.

    * In order to receive any kind of assistance, I have to pretend that bipolar is an illness, and play a lot of stupid games with mental health bureaucracies. I have yet to receive much help worth a damn from any mental health professional, but going through the system can get you a social worker and some other forms of assistance that are helpful.

    * I have been hospitalized in a county hospital after a suicide attempt, and it was extremely similar to being in jail. I didn’t get any help there at all.

    * I have yet to meet a psychiatrist that wasn’t an arrogant prick with a god-complex…

    * I would not be interested in calling my bipolar tendencies “madness” and celebrating them; I would definitely be interested in a community based around creativity, spirituality, and mental wellness in some holistic fashion, where I could potentially connect with other who struggle with bipolar tendencies, without trying to turn that into some new IDENTITY. (Please… no more fucking identity politics!!!)

  2. philphord says:

    Terrific comment, David . . . thanks so much for posting it. I especially like your thought re. “a community based around creativity, spirituality, and mental wellness in some holistic fashion.”

  3. David Hunter says:

    From the perspective of someone who has been treated for depression, using a variety of methods, including pharmaceuticals, for over 20 years.

    Pathologization has become an insult, a word of abuse to fling at a supposed opponent, such as big medicine or big pharma. At base pathology means using cause and effect to understand an illness or condition or circumstance, originally through the identification of a pathogen. Given that depression is, so far, inadequately understood, it lacks a straight-forward identification of the cause of an effect (or affect, come to that), so it can hardly be said to be subject to pathologization. Does that prevent people from ascribing causes to effects and blaming others for their condition, for their depression? Obviously not. Is it the case that in the neoliberal state depression becomes your own problem? Yes, but that is also true in other societies; though it need not be, either in the neoliberal state or anywhere else. Community is about assisting others with their trials and tribulations. That assistance comes in many forms.

    Anyone who can control their mood swings by controlling their circumstances has enviable personal strength and reach and David Powers is to be applauded for practicing what he preaches. I venture to say that most of the rest of us muddle through using whatever resources are available to us, professional, friendly, even unfriendly when necessary. Therefore I would not cast off psychiatrists, psychologists, nurses or even police officers as irredeemable. Clearly, obtaining help for “mental health” issues is even more difficult than for more mainstream medicine. Such help is less widely available, and also, perhaps more importantly, the illness category is arrayed with stigma. To overcome stigma, we must engage in identity politics. [I refer you to “The mark of shame: stigma of mental illness and an agenda for change” by Stephen P. Hinshaw (OUP, 2007).] Which is to say identify both with and as. This is not new, nor is the call innovative. Plenty of charities and celebrity spokespersons have been doing so for years. Political advocacy is necessary.

    Of course, when presenting symptoms as patients we become objects; we do so when presenting more overtly physical illnesses to other kinds of doctors. The issue is that psychiatrists know less about our “mental” illnesses and have fewer options in terms of treatments, and certainly none that are relatively side-effect free. That we (in the West, at least) put far fewer resources into trying to understand “mental” illnesses than we do into physical ones shows how deep seated stigma is. Imagine being a doctor in the eighteenth century; no knowledge of pathogens, familiarity only with gross anatomy, and herbs, spices, mercury and morphine, and bloodletting for treatments. That’s where we are with psychiatry today. Let’s not blame the doctors for being only that smart.

    Clearly I subscribe to the medical model, but that does not mean that other avenues are wrong. Rather they operate at different planes of understanding. And no relativism of belief systems here, please. Depression may currently be a mystery, but there will come a time when we can understand the complex interaction of genes, internal and external chemicals, neuronal systems, stressors, and whatever else it is that causes us to take to our beds and stay there for hours or days or weeks, uncaring as to our fate, or those of our loved ones. And for far too many, to take their lives because they see no other way of relieving their misery.

  4. philphord says:

    Hi David, thanks for your comment. My only comment in response is that I don’t share you confidence that depression will be completely understood in terms of chemicals, genes, etc., or for that matter anything else, though we’ll see (obviously it would be great if this happened). And also that multiplicity of perspective is not relativity of perspective. As I understand it, a true relativist would assert that there is no final truth, just local and contingent beliefs that are taken for truth. I do think that there is a capital-T Truth of depression, but that that truth is *irreducibly* multiple, and that any single perspective on depression leaves a remainder. If I were to cite a philosophical precedent for this kind of thinking, it would be William James’s “A Pluralistic Universe.” In terms of psychological literature, I am more in sympathy with Hillman (who describes himself as a “polytheist” thinker) than, say, Freud (a true monist).

    I very much value your thoughtful defense of the medical treatment of mental disorder, just as I value DAP’s critique of it. To have multiple thoughtful responses in the comments of this post is both to extend the intellectual scope of the original piece of writing and also to provide a true working model of the kind of multiplicity I am writing about.

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