I just presented my outline at the Sussex University, Social and Political Thought seminar. It includes a slight rejigging of the outline see below
The aim of this thesis is to look at whether there is exile in the community for those diagnosed with a mental illness, or rather , whether there ever was and whether, if there was, there still is under care in the community, specifically with respect to dominant concepts of rationality and what this means for the lifeworld. I will be utilising Foucault and Deleuze to examine the discourse of care in the community, it was in History of Madness that Foucault originally saw the treatment of the mad as exile, I will examine whether this is the case under care in the community or whether the contemporary policy of care in the community is a separate épistème. Foucault saw the disciplinary épistème, as explored in his genealogy Discipline and Punish, as separate to the épistème of exile explored in History of Madness, 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 as a whole, or rather, the diverse groupings that comprise it, and a specific 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 reciprocally 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 non-naturalistic 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)
With respect to the above, I look at how Hearing Voices Network groups work. How their internal functioning relates 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 (a central thread of HVN ethics), I examine how this works alongside Habermas’ concept of normal communication, and what implications this has for formal pragmatics. It is important here to make clear, that Habermas’ statement above relies on a definition of pathological reasoning, and that the aims of the HVN is to have the hearing voice experience accepted as non-pathological, but that currently within a large part of psychiatric discourse the experience is understood as clinically pathological. It is this precise state of affairs that makes looking at the HVN now so important. As such the HVN can be seen as a microcosm of the larger mental health survivor movement, although the larger movement has a broader range of goals. Of course here it should also be clear that this unique position of HVN with respect to clinical pathology makes its examination with respect to Habermas’ communicative rationality especially interesting. I also explore how this impacts on the debate between Habermas and Foucault and furthermore how that debate relates to this examination? I shall be utilising an unpublished thesis by Terence McLaughlin that has examined Foucauldian themes within the HVN here to help understand the history of the HVN and how it fits into this model.
I also 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. In doing so I explore these lifeworlds by examining their own critiques of the discourses that envelope them. This is a situated exploration examining the dynamics; the antagonisms and agonisms involved. The work of Cresswell and Roberts is important here.
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 try to show a certain affinity between the two, at least, I try to show where there are spaces in the lifeworld where this affinity occurs, 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. I consider whether care in the community post-asylums is symptomatic of the society of control. I examine what the recent studies of a continuous existence of some form of care in the community, at least in the British experience, that is not merely parallel but in many ways interrelated to the history of the asylums and what this implies for the idea of a society of control. If Foucault’s asylums were schooling for apparatuses of capture, has the melding of these two épistèmes contributed to the emergence of a society of control or is it merely a prescient example? I ask 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, that is, 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 re-examined for Habermas’ communicative rationality to be efficacious? And is this ultimately the irreconcilability of Foucault and Habermas’ work? Will a materialist analysis such as Scull’s help, or should we be looking to Deleuze and Guattari’s accelerationism?
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 both with and 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, and 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, Sane and the HVN itself, 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. The work of Nick Crossley shall be of much use here, as will that of Lisa Blackman. Of great importance shall be Andrew Roberts’ immense internet archive of survivor histories, and the works of survivor history researchers who I am in contact with including Andrew himself.
As previously mentioned 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 Walls of 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. 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. 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)
I shall also be looking at the DSM (the diagnostics by which medical practitioners diagnose and label mental illnesses) are used, specifically what this means 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 counter-discourses, or will this just 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, merely 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 the bases of quests for integration than change. The question is whether madness was so exiled before that it was not even a minority. A question similarly posed by subaltern studies. 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 their 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 groups 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 is 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, or a strategy of living more akin to a work of art, 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?
Madness and Theory 