Excuse the hiatus
I have had the outline of my thesis approved. For those who may be interested in what my thesis is about here it is:
Medicated Skies: A Meteorology of Mental Being
1. Aims & Scope
In my original proposal, I proposed to examine the discourse of care in the community, specifically with respect to mental health, in relation to the works of Foucault, Habermas and Deleuze and Guattari. This still remains the core of the thesis, however I think at this current time it is prudent to restrict the area of discourse examined further to that of psychosis. It is an area I already have knowledge of and, at this point in the research what I will call the pathological reasoning it entails. Of course the thesis will look closely as to what precisely is pathological about this reasoning, how this has come about, and specifically what those excluded as pathological are doing about it.
The main thesis is still to look at whether there is exile in the community for those diagnosed with a mental illness, or rather whether there ever was and still is under care in the community, specifically with respect to concepts of rationality and what this means for the lifeworld. I will be using Foucault and Deleuze to examine the discourse of care in the community, in History of Madness Foucault originally saw the treatment of the mad as exile, I will examine whether this is the case under care in the community. He saw the disciplinary épistème as separate to the épistème of exile, but I shall use Deleuze and Guattari to see how, if at all, these two épistèmes either overlap or work upon each other under the auspices of care in the community. I will then use Habermas to look at two survivor movements, the actual mental health system survivor movement itself, or the diverse groupings that comprise it, and a movement that came out of it called the Hearing Voices Network (from here on HVN) and what they mean for the critique of instrumental reason whilst looking at the implications for Habermas’ work on communicative action. Specifically I will be looking at Habermas’ own statement in the Theory of Communicative Action, Volume One, that the best way to test his theory of communicative rationality and action was against clinically pathological reasoning. Habermas (1986) suggests that there are three relevant areas of research by which one may assess the empirical usefulness of formal-pragmatic insights: the explanation of pathological patterns of communication, the evolution of the foundations of sociocultural forms of life, and the ontogenesis of capabilities for action. It is the first that interests us here. Habermas states:
‘a) If formal pragmatics reconstructs universal and necessary conditions of communicative action, it must be possible to obtain from this reconstruction nonnaturalistic standards for normal, that is undisturbed communication. Disturbances in communication could then be traced back to violations of normalcy conditions marked out by formal pragmatics. Hypotheses of this type could be examined in the light of the material concerning patterns of systematically distorted communication that heretofore has been gathered primarily in pathogenic families from clinical points of view and evaluated in terms of the theory of socialization.’ (Habermas 2007, 13)
How do Hearing Voices Network groups work? How does their internal functioning relate to Habermas’ arguments on the pragmatics of language with respect to communicative rationality? Also in light of the history of madness and the contemporary attempt to elevate hearing voices to a valid life experience, how does this work alongside Habermas’ concept of normal communication, and what implications does this have for formal pragmatics? How does this impact on the debate between Habermas and Foucault and furthermore how does that debate relate to this examination? I shall be utilising an unpublished thesis by Terence McLaughlin here to help understand the history of the HVN and how it fits into this model.
I also intend to look at how these movements have organised themselves and how they create, in a sense their own lifeworld with which to confront the World that has exiled them.
The theories of Habermas and Foucault have especially been seen as incompatible, the distinction for Habermas between strategic or instrumental rationality/ action and communicative action and the overlapping strategies of Foucault in games of power. However by reviewing care in the community I hope to show a certain affinity between the two, at least where there are spaces in the lifeworld where this happens, care in the community being one of these spaces.
A question stemming from the work of Deleuze is the idea of the society of control as a later period after Foucault’s disciplinarian society. Is care in the community post-asylums symptomatic of the society of control? What do the recent studies of a continuous existence of some form of care in the community, at least in the British experience, not merely parallel but in many ways interrelated imply for a society of control? If Foucault’s asylums were schooling for apparatus of capture, has the melding of these two regimes led to a society of control or is it a prescient example? If Habermas’ communicative action is a tool of resistance for survivors of the mental health system, then as these tools get taken up by the system is this emancipation or the creation of a new diagram of control? This may or may not rest on the acceptance of legitimacy in Habermas, what part of the project of enlightenment does it constitute? Is there an agreed, accepted or assumed teleological endpoint of reason that must a priori be accepted for Habermas’ communicative rationality to be affected, a Hegelian absolute idea perhaps? Or as Foucault’s work might suggest is this its castration and is this the element that needs to be removed for Habermas’ communicative rationality to be efficacious? Or is this ultimately their irreconcilability. Will a materialist analysis such as Scull’s help, or should we be looking to Deleuze’s accelerationism?
Whilst I have reserved the separate analyses of each different thematic chapter to each individual theorist, this thesis involves them all and where their theories pertain to a specific critique of the treatment I am using of another theorist around the analysis of a certain theme; care in the community, HVN etc. I will do this throughout the thesis. Although the aims of this thesis are in part to answer some questions and challenge some assumptions within the critique of instrumental reason and the discourse of mental health by comparing the two, there is also an aim of preparing the ground to open up new questions by creating fissures in the contemporary theoretical terrain that can hopefully be verified, falsified or criticised by further empirical and historical study, thus hopefully opening up the debate.
2. Literature Review & Theoretical Framework
The three main theorists I shall be looking at from a philosophical point of view will be Habermas, Foucault and Deleuze. If necessary I may appraise Guattari separately from Deleuze as well. Within the history of care in the community I shall be looking at Foucault, Rose, Porter and Scull as well as the work surrounding Bartlett and Wright’s investigations into the continuous existence of care in the community alongside that of the asylums. Thus I shall be looking at whether Foucault’s works, History of Madness and Birth of the Clinic chart a particular intensity of practice that may have been more totalising in the French experience as opposed to the English, resulting in the institution of psychiatry as a semi-medical practice, whilst alongside this there has been a relatively unexplored history of care in the community, especially in English practice, that now shows itself in the form of social work and community psychiatric nursing, social psychiatry etc. This leads us to the history of the HVN and other mental health social movements of which the HVN is an exemplary example at this moment in time but the milieu within which it is inextricably situated. I shall here have to rely on two unpublished PhD theses, one by Terence McLaughlin, the other by Michael Grierson, as well as utilising the histories and resources of mental health charities such as Mind, Rethink and Sane, as well as researching lesser and often more temporary user-led movements that have been influential in the creation of pressure groups and user empowerment that has enabled the HVN to take the position it does straddling practice, theory and activism.
I also intend to highlight a concurrent history of care in the community that has run alongside the history of institutionalised madness. According to Bartlett and Wright (1999) in Outside The Asylum the focus of the total asylum, as derived by Erving Goffman but attributed by critics to others such as Foucault and Scull, may have been misplaced. Approximately 40-50% of patients admitted to asylums in the nineteenth century stayed 12 months or less. Of those who left the asylum, only 1 in 5 were ever re-admitted, and admission notes from the time suggest that for a large number the causes of admission had been exhibited for months if not years before actual confinement took place, which suggests they were being cared for elsewhere. This does not take into account those (who we may argue might have been admitted but were) never admitted, for what ever reason. Bartlett and Wright (1999) argue that although asylums became an increasingly important option open to communities, they did not replace the family as the central locus of care for the insane.
The main thrust of this thesis starts for most intents and purposes at the beginning of the 19th century Britain, when a history of asylums in England and Wales that leads to a separate and distinct locus of care in the community began. In 1808 a permissive act allowed magistrates to establish rate aided, or publicly funded, pauper asylums, this was an act that merely allowed the use of these funds; such a use did not become mandatory until two acts in 1845 finally set this into law. Nine asylums were built before 1828 and a further 70 before 1901. The first asylum in Ireland was built in 1814, another 21 before 1871, whilst in Scotland the first asylum was built as early as 1781, but a Scottish compulsory act wasn’t enacted until 1887. During this time there was a ‘patchwork’ of charitable subscription institutions and an ‘uneven distribution of private licensed homes (Bartlett and Wright 1999). By 1914, 0.5% of the Irish population was classed as insane in institutions, in England and Wales it was a figure of 0.37% by 1909 with a similar figure in Scotland (Bartlett & Wright, 1999). The 1871 census of England and Wales was the first to ask householders and institutions to list ‘lunatics’, ‘idiots’ and ‘imbeciles’ the total number of whom was 69,019, of whom only 39,734 were in institutions. Census Commissioners believed this figure to be part of a widespread underestimation of those not in institutions by as much as a half. Of this recorded 30,000, some were in workhouses but by no means all. In England and Wales some of this non-institutional care was aided by ‘out-relief’, poor law payment of money or payments in kind.
Porter (2002) argues that Foucault’s ‘great confinement’ may have been true of a France under the absolute rule of Louis XIV, resulting there in troublesome people being locked in institutions not as a therapeutic measure but rather as a police measure – a result that debased madness itself, however this ‘great confinement was by no means true of the rest of Europe. Asylums hardly appeared in Russia before 1880, by the end of the 18th century there were only two asylums in the whole of Portugal, holding no more than 600 inmates. It was not until 1808 that an Act of Parliament in the UK even permitted the use of public funds for asylums and this measure was not made mandatory until 1845. Porter (2002) goes on to claim that ‘there is little evidence that Parliament or the propertied classes saw ‘unreason’ as a dire threat.’ (Porter 2002, 95) he continues ‘the use of the asylum is better seen not as an act of state but as a side effect of commercial and professional society’ (Porter 2002, 95) (Can this be seen as a Weberian/ Habermasian argument?). According to Porter a growing surplus wealth encouraged the affluent to buy services once provided at home, for example the use of private madhouses, the ‘trade in lunacy’, the keepers of which argued persuasively that seclusion was therapeutic. These private madhouses became forcing houses for the development of psychiatry as an art and science: “the asylum was not instituted for the practice of psychiatry; psychiatry rather was the practice developed to manage its inmates.’ (Porter 2002, 100)
How are the DSM (the diagnostics by which medical practitioners diagnose and label mental illnesses) used? In that case what does this mean for Deleuze’s conception of a society of control? Is there an aspect of this whereby the pathologisation of forms of rationality, especially through the behaviourist model, means that the exile within the community comes about through a disciplining of rationality? Is this indicative of a society of control? What of resistance? How have discourses counter to the dominant model fared? Has care in the community led to the possibility of a return of these discourses, or will this lead to other forms of domination justifying Foucault’s cynicism towards ‘humanism?’
Scull argues that there are three analytically distinct but empirically closely interconnected features that distinguish deviance and its control in modern society that he closely identifies with the development of capitalism: firstly, the substantial involvement of the state, the emergence of a rationalised and centrally administered and directed social control apparatuses, this can be the growth of the asylum as recognised by Foucault. Scull’s second feature is the treatment of many types of deviance in institutions that help segregate the deviants from the surrounding community, thirdly there is the careful differentiation of different types of deviance and their subsequent consignment to the ministrations of a variety of ‘experts’ (Scull 1984, 15). Is care in the community within a society of control such that with the tightening of the first and third features the second feature becomes superfluous, or does it still exist but in a psychic rather than physical form?
Do the users truly see the model of recovery as emancipatory, and do the professionals have an ideal endpoint of a discourse led model of mental health as their aim? The mental health charity Rethink has recently argued for a difference between personal recovery, that relevant to the aims of the service user, and clinical recovery, that relevant to the aims of services, i.e. something measurable. I will be exploring the HVN as resistance to the medical model. In an unpublished PhD thesis McLaughlin described this approach to Hearing Voices thus:
“For the voice hearer, and in the work derived from Romme, voices are always a reflection of the external world, have real materiality and value, and are associated with a struggle for social autonomy and human rights. They are not simply ideas or hallucinations in the idealist sense which are projected onto the world (into ideology) or as, after psychoanalysis, projective identifications – for that would be to deny their history; similarly they are not reducible to brain pathology.” (McLaughlin 2000, 54)
I will be looking at its history, its activism and the discourses surrounding this movement including that amongst professionals and academics associated with the movement, including Romme and Escher, Bentall and Read. I will be especially looking at how the HVN uses groups of voice hearers sharing their experiences as a major path to recovery.
Bentall’s recent research highlights the importance of the therapeutic alliance (the relationship between therapist and client) during the Socrates study he discovered support for the Dodo bird conjecture, everyone’s a winner, that is it doesn’t matter which therapy one chooses, they all have a similar effect, however there was a large discrepancy in the centre effects, although there was little difference between therapies there was a large difference between study centres, namely Liverpool, Manchester and Nottingham. Using statistical analysis developed by Dunn et al. (2006) he discovered that the significant factor in treatment was the therapeutic alliance.
Both Porter and Foucault talk of the humanist turn of Tuke and Pinel at the end of the eighteenth century. ‘Madness is… as manageable as many other tempers.’ (Porter 2002, 102) Tuke’s York Retreat, opened in 1796, abandoned medical treatment in favour of ‘moral means’ – kindness, mildness, reason and humanity – modelled on the ideal of bourgeois family life. The anti-psychiatry movement of the 1960s and 1970s, after Goffman, Basaglia, Foudraine and Laing attempted to move sway from the institution. Now the HVN talks of hearing voices, not as a pathological illness but as an experience, one that the hearers, with appropriate means and support, can learn to cope with, or manage.
Foucault in the Birth of the Clinic argues:
‘The mindless phenomenologies of understanding mingle the sand of their conceptual desert with this half-baked notion; the feeble eroticised vocabulary of ‘encounter’ and of the doctor/ patient relationship’ (le couple médecin-malade) exhausts itself trying to communicate the pale powers of matrimonial fantasies to so much non-thought Clinical experience’ (Foucault, 1989: xvi).
Is this what Bentall is arguing? Is this what Carl Rogers was arguing? Does it mean that such endeavours will batter themselves useless against the harsh rocks of clinical discourse? Is this what happened to Battie, Tukes, Pinel? Laing, Goffman, Foudraine? Will this form of resistance, that has many historical precedents, just usher in a new épistème of domination? One clue comes from Scull who wonders:
“in view of the elective affinity of a market system and the restorative ideal (the former emphasising the notion of a free, rational, self-determining individual, the latter the repair of a damaged human mechanism so that it once more fulfilled these preconditions for competing in the market) one is tempted to suggest that the greatly increased salience of the notion of rehabilitation reflected an indirect impact of the market on social consciousness.” (Scull 1984, 30)
Deleuze states that ‘the difference between minorities and majorities isn’t their size. A minority may be bigger than a majority. What defines a majority is a model you have to conform to… A minority on the other hand, has no model, it’s a becoming, a process… When a minority creates models for itself, it’s because it wants to become a majority, and probably has to, to survive or prosper… but its power comes from what it’s managed to create, which to some extent goes into the model, but doesn’t depend on it” (Deleuze 1995, 172-3). The question is not whether mental health movements are minorities trying to become majorities, in creating a model for themselves they have created a standpoint, and standpoints are more a the bases of quests for integration than change. The question is whether madness was so exiled before that it was not even a minority. Another question is that in becoming lines of flight are created but to what extent does the becoming a majority relinquish their sense of being? A problem here as it is the denial of being that may be the creation of the symptom that requires the creation of a minority in the first place. In what sense is integration any different from the maintenance of the medical model, unless ‘cure’ is sought within the integrative experience? Deleuze argues that the society of control ‘operates through continuous control and instant communication’ (Deleuze 1995, 174). He goes on to say that ‘Creativity has always been something different from communicating. The key thing may be to create vacuoles of non-communicating, circuit breakers, so we can elude control.’ (Deleuze 1995, 175) In this case for the voice hearer looking for change rather than integration, so that they may regain their sense of being what purpose does the HVN represent? Deleuze suggests ‘It definitely makes sense to look at the various ways individuals and groups constitute themselves as subjects through processes of subjectification: what counts in such processes is the extent to which, as they take shape, they elude both established forms of knowledge and the dominant forms of power. Even if they in turn engender new forms of power or become assimilated into new forms of knowledge’. (Deleuze 1995, 176) It is the make up of these groups as lines of flight as well as integration that is worth studying. For this reason it may be worth looking at the voice hearer speaking in the group as Parrhesiast as opposed to Schöne Seele.
However as those diagnosed with a mental illness are coming from the perspective of being excluded from the mundane rationality of lifeworld, either by self-stigmatisation or actual stigmatisation by the ‘sane’ members of the lifeworld who see their insanity as irrational, due to psychosis, do these movements have to create their own communication internally to validate their own lifeworld for acceptance into larger diagram. Is this resistance? Does it involve emancipation or mere integration into a larger diagram? I shall particularly focus on the HVN’s attempts to forge a new discourse where hearing voices is seen as a normalised experience shared by a larger than previously accepted proportion of the population. There is a difference between irrationality and insanity, if the dominant lifeworld refuses to recognise the rationality of the insane, what does the incorporation of their lifeworld do to the dominant lifeworld, which as the work of Foucault and Deleuze should show contains its own power games and has a historical nature, through the actions of this resistance? Using this analysis I shall compare it to Habermas’ work as a study of pathological rationality as he suggested.
One potential means is to examine the ground rules or ethics of participation in hearing voices groups and compare them with Habermas’ discourse ethics.
Following Weber, Habermas argues that ‘communication requires an interpretation that is rational in approach (Habermas 2007, xvi), and that social reality isn’t exhausted by the ideas embodied in it. Weber showed that these ideas change in response to forces and factors that cannot be explained by an inner logic. In Volume 1 of the Theory of Communicative Action, Habermas argues that it is precisely to prevent Weber’s thesis of a return to polytheism that a pragmatic logic of argumentation is required (Habermas 2007, 249). If Foucault recognises this polytheism and its repression or refusal of acknowledgment as cause of exile, is there a reconciliation whereby hearing voices group are a return to the dominant lifeworld in an emancipatory way using or creating its own institution? Or is this an immanent critique of the situation these subalterns find themselves in, finally acknowledging the polytheism they are embroiled in? It may not be possible to explain the ideas purely by an inner logic but what happens when these forces and factors develop ideas that distort individual inner logics? Is it necessary to forge new avenues of communication to resist this colonisation? What is the telos of hearing voices groups? Habermas argues all claims in speech acts can be contested, yet the ethos of hearing voices group is that the belief of the voice hearer be accepted, it is ok for others to contest the reality of the experience by contesting the claims, but in a sense the right for the voice hearer to hold their beliefs is inviolable. Habermas argues that the giving of reasons-for and reasons-against has traditionally been regarded as fundamental to the idea of rationality. Therefore for Habermas the achieving of mutual understanding in communication free from coercion is key to the idea of communicative rationality. Much is made in mental health survivor movements of being listened to, as an offshoot of this, hearing voices groups provide a place for peer-to-peer listening support. As a form of communication this undoubtedly requires mutual understanding free from coercion and so can be understood as rational in that sense but it does not necessarily require consensus beyond mutual respect for each others beliefs. This hinges on the translation of Vestehen and to what extent it was important for it to usually mean consensus as opposed to a variant of mutual understanding similar to the idea of agreeing to disagree. Or as Foucault put it, respecting each others’ truths as opposed to agreeing on a truth, do we require the Parrhesiast living a truth rather than the beautiful soul trying to drag the life-world into their view, lost in their experience of the world as an impersonal, inflexible Other with whom one cannot agree as consensus has been denied them?
3. Structure of Thesis
Background and purpose to the thesis
ii. History of Care in the Community
Looking at how the dominant discourse emerged that is manifest in the discourses of law and medical practice, what other discourses exist in practice; phenomenological approaches, anti-psychiatry etc. What placement in the community does for these discourse(s)?
iii. Foucault, Deleuze & Guattari.
If the asylum was a form of confinement as exile from the community for Foucault, what does this mean for care in the community? Do we no longer have confinement or exile? If we do have them, is the exile or confinement by means of rationality and affect. If so how is this contained in the community? Can we see Care in the community as a new diagram, with medication and diagnosis as the technological apparatus? It may be necessary to review Roy Porter (and others) challenge that confinement was not as prominent in the UK.
iv. Survivor Movement and Hearing Voices Network.
I will be looking at the idea of Survivor movements as resistance? Are these only possible in the new diagram? How do they function in the new diagram? I propose to look at the development of the recovery model through the activism of survivor groups and its subsequent incorporation into the mental health services. I will look at the different views of the recovery model from the aspect of users and professionals.
I shall explore the Recovery movement and HVN as communicative rationality. Habermas states:
“If we assume that the human species maintains itself through the socially co-ordinated activities of its members and that this co-ordination is established through communication – and in certain spheres of life, through communication aimed at reaching agreement – then the reproduction of the species also requires satisfying the conditions of rationality inherent in communicative action.” (Habermas 2007, 397)
The aims of these movements seems to either have a strategic intention of well-being’ or at least a ‘being’ that is otherwise curtailed, that would therefore assume the need for communicative rationality, in the case of the Recovery movement, or as a therapeutic goal they use communicative rationality, where ‘well-being’ is seen as an incidental effect as opposed to the strategic aim, in the case of the HVN.
Whatever I conclude from the research, hopefully this will include answers as to whether the analysis of pathological rationality affects Habermas’ communicative rationality, and from that whether this result affects the debate with Foucault and can bring forth an answer to the impasse between them. Hopefully this research will also answer whether Deleuze’s control stems from a confluence of the épistèmes of discipline and exile, whether this does lead to a new society of control. If so does this suggest Foucault’s argument that epistemic change is a break or fracture and in fact is a gradual process or does this show that the humanistic affects of action such as Habermas’ communicative action merely lead to new forms of domination? That although they incorporate resistance at some point a fissure appears and a new épistème is created?
5. Preliminary Bibliography
Bartlett, Peter, and David Wright, eds. 1999. Outside the walls of the asylum : on “care and community” in modern Britain and Ireland. New Brunswick N.J.: Athlone Press.
Deleuze, Gilles. 1995. Negotiations, 1972-1990. New York: Columbia University Press.
Habermas, Jürgen. 2007. The Theory of Communicative Action, Vol. 1: Reason and the rationalization of society. Reprint. Boston [u.a.]: Beacon Press [u.a.].
McLaughlin, Terence. 2000. Psychology and mental health politics: a critical history of the hearing voices movement. unpublished Phd thesis, Department of psychology and speech pathology, the Manchester Metropolitan University.
Porter, Roy. 2002. Madness : a brief history. Oxford ;;New York: Oxford University Press.
Scull, Andrew. 1984. Decarceration : community treatment and the deviant : a radical view. 2nd ed. Cambridge: Polity.