Thursday, 15 May 2008

Listening to Madness

Whether in politics, philosophy or psychology, extreme and opposing views have an unfortunate tendency to appear to define the field and scope of our options. Accordingly, real theoretical innovation can depend on our being able to notice what non-mandatory assumptions are shared by both extremes, assumptions which prevent the novel and genuine development of our understanding.

The only example (aside from what I'm shortly going to write about!) which comes to mind will probably be too obscure for many. But let's risk it: In the philosophy of mathematics, the doctrines of Platonism and Conventionalism have been thought of as two option-limiting extremes. (In metaphysics, we have Realism and Idealism often playing a similar role to Platonism and Conventionalism.) Platonism tells us that our mathematical truths are true in virtue of their correctly describing a mind-independent Platonic world of sempiternal hard as crystal facts. Conventionalism tries to bring us down to earth, instead suggesting that necessary truths (including mathematical truths) are true in virtue of how human beings in their communities 'go on'. The former preserves necessity at the expense of invoking spooky words we don't know what to do with (Platonic realms); the latter preserves naturalism at the expense of necessity (since if we change how we go on, the necessary truths will no longer be true). Both views share the idea that necessary truths are true in virtue of something - that they are to be modelled, in this sense, on empirical truths. (The Wittgensteinian solution is to accept that necessary truths are not descriptions of our conventions, but are our conventions.)

At any rate, the two extremes I wish to consider in this post are (particular forms of) existential and psychiatric takes on 'madness'. A caricature of the latter (which caricature of course serves my purposes well) may promote the idea that there is nothing to be heard when we 'listen to madness' other than noise. What the 'mad' person says simply reflects their 'broken brain'. The tempting task of trying to discern a hidden meaning in what is said is thought of as thankless and pointless. We would do better ministering to material needs and waiting for the drugs to kick in. A caricature of the former (i.e. of the existential position) reverses this diagnosis. Madness is simply another way of going on, another way of being human, and we have to learn how to listen to the meanings implicit in what the 'mad' person is saying. Our deafness to these meanings reflects our own shortcomings in decoding the cryptic yet ultimately fathomable messages that we are given.

These two extremes, it seems to me, share a fundamental assumption, an assumption that prevents us from making psychological headway in understanding the nature of madness. To put this assumption in a form which makes denials of it look ludicrous (if pithy): it is assumed that when we understand something psychologically, what we understanding is its meaning. The alternative I want to promote, here, is the idea that what we may better do is to learn to tolerate, stand amidst, madness, to feel the full force of its pull on us to comprehend it (i.e. not to run away from it like the psychiatrist), without ever supposing that we really might or could and without supposing that a failing to do so would down to the listener (i.e. unlike the existentialist). For it seems to me that in order to do justice to the 'mad' and to madness, we need to find a way to listen to precisely what is mad about madness.

Psychiatric labels, it seems to me, are unhelpful in ways other than is commonly supposed. They are unhelpful because, once we learn to apply them, we can stop thinking about the utter bizarreness of the phenomena they are used to describe. Oh yes, he is 'hearing voices in his head', she is 'seeing things that aren't there', she is experiencing 'thought insertion' or 'thought broadcast' or 'thought withdrawal' or 'made actions'. He 'delusionally believes that he is the messiah'; she 'delusionally thinks that the secret services are watching her every move'. "Ah yes, they are mad, of course, and these are their symptoms; next case please". Or alternatively: "Let's pause to see what sense we can make of what they are saying, what distorted truths they contain".

There are many things that are right in the two extremes I have already outlined; I find myself very sympathetic to that which I labelled the 'existentialist'. Yet my concern here is with ways of approaching madness which, despite their desire to genuinely engage with and find meaning in what is said, thereby assimilate the mad to the sane, assimilate what is constitutively nonsensical to the sensical. The very madness of the mad can thereby be overlooked. We find such approaches in the mainstream of today's clinical psychological approaches to psychotic symptomatology. For example, perhaps it is believed that sense can be made of thought insertion if we distinguish a sense of agency and of ownership for thoughts, and see thought insertion as involving a failure in just one of these psychological mechanisms. My belief, though I shall not spell it out here, is that all such (neuro)psychological approaches tacitly assimilate the insane to the sane, and that it is this tacit assimilation which gives rise to the appearance of explaining psychosis through supposedly explaining the symptoms. (This comes about because it is assumed that we really can isolate such individual contributions to thinking or believing - that thought or belief can be understood as due to the collaboration of independent psychological mechanisms. Or that we, say, normally identify our own thoughts or feelings as such, yet develop a trouble epistemic relationship with ourselves when we become mad.)

But what is it to listen to madness, then? Well, the psychiatrist does not trouble themselves with why it is that what the patient says does not make sense. They recognise it (for example) as nonsensical in a delusional way, and diagnose it as such. But psychiatry famously lacks an adequate reflective account of what it is for a belief or other such attitude to be a delusion. A good place to start to listen might simply be to listen to the ways in which the 'mad' person feels compelled to say what they do, and to track too the ways in which sane listeners - ourselves in our sane moments - feel compelled to try to understand, or to shun understanding of, what we are being told.

The truth, I believe, is that the very ideas of hallucination, thought insertion, and delusional belief are as crazy as the phenomena that they are supposed to track. It makes no sense to say that I see something that isn't there, that I believe something that defies belief, that thoughts are put into or taken out of my mind, that I receive messages in my head. Psychiatrist/Existentialist: "Well of course I'm not saying that the person really does do these things; I'm saying that they take themselves to be doing this." Well perhaps we can sanction this in the case of hallucination, although it isn't clear to me that we really have the language to do justice to this, nor that psychotic hallucinations such as hearing of voicse are aptly understood in this way. (For example, we say: it 'seems to him' that he sees something that is not there; but in what does this 'sensory seeming' really consist? It is 'as if' I am seeing something, but am not seeing something. 'For me it is as if'... The phrases come naturally, but it's hard to know what to do with them...) But in cases of thought insertion or incomprehensibly delusional belief, what is meant by a phrase such as 'It is for him as if a thought has been removed from his mind'.

The claim I want to stress is as follows: We are driven in psychiatry to use phrases such as 'as if' clauses ('as if a thought has been removed') although we don't have any meaningful grasp of the comparison object. And whilst it is tempting to believe that the important thing to do is to furnish ourselves with just such a grasp or simply to move on to something that does make sense (the existential and psychiatric alternatives), what we might benefit from could be a willingness: To sit with the phenomena, hear their craziness, hear how both the patient and the listener are driven to say things that don't make sense in order to 'do justice to' the experience. To note how the nonsensical descriptions are actually constitutive of the experiences in question: they are the experiences which we find ourselves compelled to characterise in this way.

My plan, then, is to learn to listen to madness itself. In particular it is to begin to spot all of those occasions in which the patient or the doctor is driven to say 'Here it is as if 'x'' where x is not something that we can really understand. Moving from prodromal to apothanic stages of psychosis we see such 'as if's' dropped and the person now really starts to 'delusionally' believe in these impossible beliefs. It occurs to me that, to the extent that a person's madness is at the time an important part of them, learning to listen to madness might also be a way of learning to listen to my patients. Perhaps my own acceptance of their madness, without explaining it or dismissing it, may even be a beneficial experience for those to whom I am trying to listen.