Madness by Design: A Genealogy of an “Anti-Tradition”

Introduction

There is a widespread contemporary assumption that psychiatric conditions can be uniformly regarded as mental disorders or dysfunctions of the mind. Yet there is a wealth of historical theorizing about the mind that conceives of these conditions as functional, useful, or adaptive, in other words, in some sense, as a matter of design. This rich intellectual legacy is the topic of Justin Garson’s penetrating study, Madness: A Philosophical Exploration (2022). In this paper, I propose to read Garson’s book as a genealogy of the “anti-tradition” that he labels, variously, as “madness-as-design” or “madness-as-strategy”. Viewing the theoretical approaches that he analyzes through this genealogical lens has two benefits. First, it encourages us to identify other instances of madness-as-design (or madness-by-design1), particularly those with an overtly political dimension on the contemporary scene. Second, it should lead us to question the category of madness itself, which turns out to be radically disjointed, particularly since it cannot be unified under the rubric of disorder or dysfunction.

1. Madness-by-design as genealogy

Garson states at the outset that his work is neither a history of science, nor a genealogy. But I think it would be too hasty to take this overly modest statement at face value. The book certainly traces a particular theme through a number of historical authors and texts discussing various conditions of the mind. It is thereby a selective history of the topic that pays close attention to certain texts and their arguments, albeit less attention to their social contexts and political backgrounds. As such, it is more of an inquiry in the vein of history of philosophy than intellectual history,2 meticulously reading the texts in question, from Hippocrates to Wakefield, and advancing interpretations of their views, without attempting to situate them in their respective historical eras in any detail. But the book can also be usefully seen as a genealogy, roughly in the Nietzschean or Foucauldian senses of the term.3 If we take “madness” as the central concept under examination, there is arguably an attempt in this work to trace a neglected lineage for this category, and one that conforms to some of the features that have been associated with the concept of genealogy, as I will try to argue in this section.

Garson has done philosophers of psychiatry (among others) a major service in excavating a history of theorizing about the mind that does not see mental conditions as disorders. Rather than mental disorder or dysfunction, this body of work regards “madness” as a matter of design or adaptation. An alternative title for this book might have been “madness by design”, which is a phrase used by Garson at certain points to capture in dramatic fashion the radical idea that is being argued for here. Moreover, he groups many things under this rubric, including divine providence, natural law, physiological mechanisms, natural selection, and even malingering on the part of patients.4 He shows how various historical figures have regarded allegedly dysfunctional mental conditions as products of natural or supernatural factors that are integral to the way that the world is ordered. Far from being aberrations or exceptions to the order of things, they are best regarded as a result of one or more of these factors, no less than the minds of “sane” or “normal” individuals. Garson characterizes the mad-by-design approach as an alternative to the standard view that madness is a matter of disorder or dysfunction:

In doing so, he draws our attention to a neglected perspective in theorizing about the mind. Indeed, it would be more accurate to say that he elevates or promotes it to the level of a perspective, since it does not self-identify as such and it includes such variegated views. At the same time, Garson is at pains to emphasize that he does not regard “madness-as-design” as a tradition, even though it serves as the unifying theme of the book. In fact, he contends that its opposite, madness as dysfunction, is a tradition that “organizes itself into a proper narrative”, but madness as design is “is like a child that interrupts that narrative from time to time, but each time in a different costume” (26). He also refers to madness-as-design as an “anti-tradition” (248).

However, I would argue that rather than characterize madness-as-design negatively, by contrast with its opposite, as a non- or anti-tradition, it might be cast in more positive terms. It is arguably not a tradition in the sense of a connected chain of ideas that refer to one another and build consciously on one another, but that does not prevent it from conforming to some of the features of a genealogy, as I understand them. For some of the writers Garson discusses, madness is a matter of divine retribution (25), while for others, it constitutes a means of redemption furnished by God (42), and for yet others it is a natural consequence of the way that our bodies are constituted (65). As he shows, there are a variety of ways in which this core idea is defended by various authors, some religious and others secular, some mentalistic and others biological, some evolutionary and others psychoanalytic. This chimes with Foucault’s insistence that genealogy does not impose unity or fabricate an identity, but rather “fragments what was thought unified” (1977, 82).

Second, the historical lineage contains within itself many discontinuities rather than an uninterrupted course of continuous descent. Garson ingeniously finds evidence of the thesis even in authors who think of madness primarily as dysfunction. This is perhaps most prominent in the eighteenth and nineteenth century authors he discusses:

Effectively reading some of these texts against themselves, Garson shows how even Kant, who viewed madness as a series of disorders of our mental faculties, endorses the idea that madness has a goal-directed character, since “defective reason still attempts to systematize its mad productions” (90). Similarly, Wigan, who conceives of madness as the product of a divided brain, holds that “Madness must harness or co-opt reason; it must compel reason to serve its own perverse end”, much as autoimmune diseases harness the body’s immune system to a harmful end (111). In these cases and others, we see “accidents”, “minute deviations”, and “complete reversals” in the history of the notion of madness-by-design, just as was posited by Foucault (1977, 81) for genealogy in general.

Finally, Garson resists the temptation to distill an essence out of this tendency or to anchor it in a single origin. Despite the fact that he begins his story with ancient conjurors and magicians, and notwithstanding the fact that he sometimes detects echoes of this ancient line of thought in later authors, he is also at pains to deny that the authors under discussion can be regarded as heirs to the ancient magicians. The concept of madness-as-design does not have a single origin or ancestor and it consists of “resonances” (26) and echoes rather than descendants or offspring. This, again, squares with Foucault’s disavowal of the quest for origins and insistence on “numberless beginnings” (1977, 81).

Even though there is not a single tradition of madness-as-design, Garson’s narrative is not just a selective history of psychiatry, foregrounding a number of eccentric contributions. The features I have highlighted, including multiplicity, discontinuity, and absence of origins or foundations, seem to be recurrent properties of genealogies, as posited by writers like Foucault and others. Moreover, I would argue that seeing madness-by-design as a genealogy has two benefits. First, it should encourage us to look for other exemplars of theorizing about madness in this vein, and hence, to reconceive psychiatric conditions without the burden of dysfunctional thinking or the concept of disorder. In particular, I would argue that it highlights the value of understanding at least some psychiatric conditions as expected responses to certain social and political regimes. Second, it should lead us to question not just the concept of “mental disorder”—since the second half of that label is now rendered moot—but indeed even a unified notion of psychiatric condition, or the idea that there is such a thing as “madness” in the first place. In the rest of this paper, I will pursue both of these leads. In section 2, inspired by Garson’s genealogy, I will make a suggestion as to how one could extend his account to other significant cases of madness-by-design, notably those that have an overtly political character. In section 3, I will try to use Garson’s analysis to push back against the notion that there is such a thing as madness in the first place, that is to say, against the idea that madness is a real or natural kind.

2. Madness as a matter of social and political design

Garson has done a prodigious amount of research on a fascinating cast of characters in the history of psychiatry. While some are well known (e.g. Burton, Krapelin, Freud), others are much less so (e.g. Wigan, Griesinger, Goldstein), and yet others are well known but not for psychiatry (e.g. Locke, Kant). These figures represent a range of different approaches to conceiving of madness in terms of design, but one aspect of the madness-by-design perspective that does not appear to be in evidence before the twentieth century has to do with the social and political causes that can give rise to madness.5 Greater awareness of the social factors in the ontogenesis of madness may be one virtue of late twentieth and early twenty-first century psychiatric theorizing, as the “biopsychosocial” model of madness has gained ascendancy in the past few decades (Bolton and Gillett 2019).6 However, the political element is seldom highlighted as a separate causal factor, giving rise to what might be labelled a “biopsychosocio-political” model. In Garson’s genealogy, the most overtly political spin on madness-as-design can be found in the work of R. D. Laing in the mid- to late-twentieth century, but Laing’s analysis of the relationship of schizophrenia to capitalism is less than convincing and not widely credited, at least nowadays. Nevertheless, the political dimensions of madness are worth taking more seriously and can be illustrated by the analysis of other forms of madness provided by other theorists, or so I will try to argue in this section.

An instructive instance of political madness-by-design may be found in the recent colonial past. As is well known, the great theorist of colonialism, Frantz Fanon, was trained as a psychiatrist and dedicated a large section of his work, The Wretched of the Earth (1963), to a series of psychiatric case studies meant to illustrate the ways in which the realities of colonialism, military occupation, indiscriminate killing, torture, rape, house demolitions, and a host of other forms of violence inflicted on the natives by the settlers impacted their mental health. Fanon even refers to colonialism “in its essence” as “taking on the aspect of a fertile purveyor for psychiatric hospitals” (1963, 249). While disavowing writing a scientific work and eschewing arguments over “nosology” and “therapeutics” (1963, 251), Fanon posits that colonialism, “is a systematic negation of the other person and a furious determination to deny the other person all attributes of humanity” (1963, 250).

Though Fanon does not attempt to provide a causal or mechanistic account of the ways in which denial of humanity might lead to depression, delusion, impotence, homicidal compulsion, and a myriad other mental conditions, he evidently recognizes these symptoms of madness as predictable outcomes of the pathological state that is colonialism. He states that some of his cases are clearly “reactionary”, being the direct effects of the unspeakable crimes of colonialism, but most “give evidence of a much more widely spread causality although we cannot really speak of one particular event giving rise to the disorders” (1963, 252).

To illustrate, he relates a case of homicidal impulses on the part of an Algerian who was the survivor of a mass murder in his village by the French authorities (1963, 259-61). He also describes a case of depression, hallucinations, and “anxiety psychosis” in an Algerian man whose mother was killed by the French and who had subsequently killed an unarmed woman colonist while fighting with the resistance (1963, 261-4). He details cases of “noise phobia”, insomnia, and sadistic tendencies in a group of children whose parents had been killed by the French and who had been displaced by fighting and sent to live in Morocco or Tunisia (1963, 277-8). Fanon dedicates a separate section to the symptoms of victims of torture, which include standard psychiatric conditions such as depression and apathy, as well as more recherché symptoms such as “electricity phobia” (specifically in victims of torture by electricity), inhibition, and phobia “of all private conversations” (1963, 280-293). Moreover, he thinks that colonialism does not just produce madness in its primary victims, colonized peoples, but in the colonizers and the enforcers of the colonial order, including the French police inspector who tortures his wife and children (1963, 267), or the French policeman who develops depression as a result of his participation in the torture of Algerians (1963, 264).

Perhaps the most disturbing case discussed by Fanon is that of two Algerian boys, ages 13 and 14, who kill their French playmate on the grounds that “the Europeans want to kill all the Arabs” (1963, 271). They go on to explain: “We can’t kill big people. But we could kill ones like him, because he was the same age as us” (1963, 271). When asked why they chose to pick on their friend in particular, their matter-of-fact response is: “Because he used to play with us. Another boy wouldn’t have gone up the hill with us” (1963, 271). The childish directness of their answers combined with the cold-blooded ruthlessness of their reasoning are related without comment by Fanon, notably without attempting to impute causality. But it is clear that he thought that these and other behaviors that he saw in his clinical practice were an integral feature of colonialism.

After detailing the ways in which French colonial psychiatrists attributed to Algerians in particular, and North Africans or Arabs in general, a criminal mentality and character traits of aggressivity, lack of emotivity, persistent obstinacy, mental puerility, and impulsivity, among others (1963, 294-304), Fanon proceeds to offer an alternative account:

In other words, it is the anticipated effect of a situation of systemic violence and dehumanization. For Fanon, the pathologies of his patients are the normal response to a pathological system of oppression. Indeed, he turns the tables on colonial psychiatry by asserting that the alleged laziness and intransigence of natives under colonial domination are in fact not pathologies at all, but the natural state of resistance to colonialism. He writes:

If there is dysfunction here, it is to be found not in the colonized people but in the political regime of colonialism, which is the real site of pathology. The colonial situation seems to fit well within Garson’s general rubric and would make a valuable addition to the genealogy of madness-by-design, specifically one with an overtly political dimension.

This political extension of Garson’s genealogy helps relocate some sources of pathology in the contemporary world, by displacing them from the individual to the broader political context. It would be a mistake to think that the colonial era is entirely a thing of the past, since colonialism persists in the world in such places as Palestine/Israel, where a century of colonization has wreaked havoc on mental health. Here, too, colonial dispossession and denial of self-determination can be seen as a “fertile purveyor for psychiatric hospitals” (though hospitals, clinics, and trained professionals are exceedingly scarce in occupied Palestine; see Giacaman et al. 2011). Moreover, this political setting also reveals the inadequacy of standard psychiatric categories such as “post-traumatic stress disorder” (PTSD), which ignore the political context or implicitly assume a default political context from the global North. Although PTSD is the most commonly reported psychiatric condition among Palestinians in the occupied territories, Palestinian psychiatrist Samah Jabr articulates the problematic nature of the diagnosis:

In such contexts, psychiatric conditions are not rightly seen as disorders at all but as indicators of a disordered political regime:

Other researchers on mental health and well-being have also warned that ignoring the “driving force of political conditions” risks locating the source of pathology in individuals rather than political contexts (Barber et al. 2014, 101).

The enduring relevance of madness-by-design as a political phenomenon can also be demonstrated with reference to its recurrence in the era of global climate change. In the Anthropocene, the mental condition of what has been called “climate anxiety” (also “climate panic” or “eco-anxiety”) has become widespread, and is arguably a rational, or at least natural, response to the climate emergency. As one researcher puts it, again displacing pathology from individuals to their circumstances: “the climate crisis does not just induce trauma under certain circumstances—it is a new form of trauma that pervades the circumstances of our life” (Woodbury 2019, 1; original emphasis).

Some writers have distinguished two ways in which climate change impacts mental health. The first includes the direct influence of extreme weather events and natural disasters on people’s states of mind, for example those who have been displaced or forced to migrate as a result of climate change. The second involves anxiety about climate change, which can affect even those who have not experienced direct impacts and can include concerns about harm to future generations. Particularly when it comes to the latter, Clayton stresses that “[i]t is important to avoid pathologizing the emotional response to climate change” (2020, 3). As in the case of colonialism, a pathologizing approach can serve to direct “attention toward individuals and away from the social causes and possible social responses to climate change” (Clayton 2020, 3). Moreover, intervention techniques that rely on cognitive reframing to de-emphasize or deny the threat, are both unlikely to be effective and do not promote the well-being of society at large (Clayton 2020, 4). Indeed, they would seem to be morally and politically reprehensible. By contrast, there is some evidence to suggest that working to mitigate climate change is a more effective intervention and some studies show positive correlations between happiness and “pro-environmental or sustainable behavior”, based on research conducted in Mexico (Corral-Verdugo et. al 2011, 102). Far from being futile, political resistance may improve mental health as well as change policy. This means that supposedly extreme reactions to the climate emergency cannot be seen as dysfunctional or disordered, but in some sense at least, as a matter of design.

3. Is there such a thing as “madness”?

As already emphasized, there is a great deal of variety in the ways in which forms of madness can be seen as instances of design, as opposed to disorder or dysfunction. Garson’s philosophical history of madness-by-design presents us with numerous routes to conceiving of mental conditions as “features” rather than “bugs”, ranging from punishments for sins to biological adaptations. Indeed, for some of the thinkers discussed by Garson, it would be a stretch to say that madness is a matter of design from the perspective of the authors themselves. At best, it emerges from his inventive interpretations of their work; indeed, in some cases, it requires a kind of “contrapuntal reading” of the texts (cf. Said 1993). This is not a problem for a genealogical account, which is meant to be disunified and disjointed, but it may be a problem for any attempt to delineate a unitary concept of psychiatric disorder (or closely related concepts, such as psychiatric condition, mental disorder or mental illness).

In this section, I will argue that reflection on madness-by-design ultimately serves to undermine the existence of a unified category of psychiatric disorder and related categories. This conclusion has been pressed by others, but I think that Garson’s inquiry gives us further reason to doubt the validity of such a construct. In making this case, I will adopt a realist but non-reductionist approach, according to which scientific categories (including psychiatric ones) aim to identify natural (or real) kinds, and that these kinds are associated with aspects of the causal structure of the world (including the structure of the human mind).8

Many attempts to characterize psychiatric conditions consider them to be dysfunctions and regard dysfunction as a necessary condition for something to be a psychiatric condition. But if the madness-by-design perspective is an apt characterization of at least some psychiatric conditions, then there does not appear to be a common denominator among all these conditions. While some may result from biological dysfunctions pertaining primarily to the individual and would recur across a broad range of social environments, others may just be functional responses to social stressors, for example. Given the heterogeneity of their central features as well as their causes and effects, there would seem to be no basis to group them together as members of a single kind.

Even if one disagrees with many of the specific claims made by proponents of the madness-by-design perspective, collectively they lend credence to the idea that there is a great deal of heterogeneity among the conditions lumped together in the category of psychiatric disorder. This heterogeneity is not alleviated if we substitute the label “psychiatric disorder” with such terms as “psychiatric condition”, “neurodiversity”, or even “madness”, since it pertains to the assortment of conditions that are generally grouped together under these labels. The category of psychiatric disorder is thought to include such diverse conditions as autism, depression, schizophrenia, and post-traumatic stress disorder, which seem to have nothing in common apart from the fact that they are conditions of the mind-brain that are commonly thought to be dysfunctional in some way. But if mind-brain dysfunction is not a common denominator, then it cannot give unity to the category, and there does not seem to be anything else that pertains to psychiatric conditions as such.

This claim about the category psychiatric disorder (or madness) does not prevent some specific psychiatric conditions from being real kinds (e.g. schizophrenia, autism) (cf. Beebee & Sabbarton-Leary 2010). Although that might seem paradoxical at first sight, there is no tension in principle between asserting that a superordinate category does not correspond to a real kind while some of its subordinate categories do. (Compare: pet is probably not a real kind either in biology or the social sciences, but dog and goldfish are real biological kinds.) Now, it may be thought that the same obstacles to kindhood that apply to the superordinate category also apply to the subordinate categories. But this does not seem warranted, since at least some psychiatric conditions are relatively homogeneous, unlike the superordinate category that they are usually subsumed under.

One might object to this proposal to eliminate the category of psychiatric disorder on the grounds that it would undermine the very basis of psychiatry. If the category psychiatric disorder does not correspond to a real kind and the conditions that it studies are disunified and not subsumed under a single umbrella, should the field splinter into a number of different disciplines, each dedicated to one or a subset of conditions? Would this not have an adverse effect on both empirical research and clinical practice? And will it lead eventually to the elimination of psychiatry as a viable branch of medicine?

The implications of this conclusion for psychiatry are significant but need not lead to such consequences. There are other domains of medicine that study diverse sets of phenomena. After all, pediatrics investigates and treats a variety of different conditions that affect children, though there is no unified category of “children’s disease” or “sick kids”. Some of these conditions are rightly regarded as dysfunctions while others are not, for example symptoms like fever, vomiting, and diarrhea that help the body to combat bacterial infection, or allergic reactions that serve to stave off allergens (cf. Lillienfeld and Marino 1999). Similarly, psychiatry can be conceived as a discipline that focuses on a range of conditions pertaining to the mind-brain, using a diverse set of methods and deploying a wide variety of interventions.9 But rather than view all of these phenomena as disorders, it would be better to regard them as distinctive mental conditions or dispositions.

It is also worth considering another objection to denying that there is a valid scientific category that groups together all psychiatric conditions. It might be said that the above considerations apply to the category of psychiatric disorder, but not madness. However, the two terms are roughly coextensive and both are used to denote a heterogeneous collection of conditions, at least some of which may be adaptive in various contexts. Since that applies to the set of conditions discussed under this general rubric, whichever label we use, the substantive point is the same. But, it might be protested, if we eliminate madness as a category, that might have lamentable consequences, since especially when reclaimed by those who are collectively labelled as “mad”, it can result in solidarity and a sense of common cause, as in the movement for “mad pride”. To be clear, I have cast doubt on the concept primarily as a category for scientific research, not one for building support and solidarity among those who have been pathologized. If it is understood as a category that aims not at identifying a real kind of condition, but one that can serve a moral or political purpose, then it may be worth retaining, as long as we do not consider it to identify a real kind in the biomedical or social sciences. Even though this may not have been Garson’s intention, I submit that his project leads us inevitably to question the category madness itself. The category can be seen to have played the role of Wittgenstein’s ladder in his inquiry: a useful implement for reaching a destination that can be dispensed with by the end of the exercise.

4. Conclusion

In this paper inspired by Garson’s book Madness: A Philosophical Exploration, I have tried to make a case for three broad claims. The first is that despite his demurrals, Garson has effectively provided a genealogy (roughly in the Foucauldian sense) of madness-by-design, a historical perspective on psychiatric conditions that conceives of them as (in some sense) a product of design rather than dysfunction. The second is that this genealogy can be used to identify other instances of adaptive or designed psychiatric conditions in the contemporary world, notably those with an overtly political dimension. The third is that Garson’s genealogy ultimately leads us to question the superordinate category madness, since this historical exploration lends further support to the contention that it is thoroughly heterogeneous. To put it more succinctly: there is no such thing as madness and Madness is a book about it.10