Table Of ContentMADNESS CRACKED
m i c k p o w e r
M A D N E S S
C R A C K E D
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For Charlie
–with lifelong thanks
PREFACE
Almost anything that has been said about madness, and almost any approach to
what madness is, has some grain of truth in it, and every proposal that comes
down on one side is guaranteed to be vehemently disagreed with by opponents from
several other sides. Let us therefore consider in shorthand what some of these dis-
putes are by beginning with the following two examples:
John believes that he is mad, but he isn’t.
Tom believes that he is not mad, but he is.
These sentences summarize some of the conundrums that face any discussion or
review of how we approach the question of madness. If we take a purely subjec-
tive approach to madness, John would be mad because he believes himself to be so,
whereas by the same subjective logic Tom would not be mad because he does not
believe himself to be so. Many practitioners working in clinical psychology might
well endorse this subjective approach. For example, a client who suffers from
panic attacks and believes that he is mad might well be offered a cognitive therapy
intervention including challenging his beliefs about madness. Equally, a clinical
psychologist working with Tom, who is hearing voices but who doesn’t believe
himself to be mad, might well be happy with Tom’s belief and make no attempt to
challenge it, while providing better coping mechanisms for managing his voices. In
other words, the subjective approach to madness is alive and well and helps clients
on a daily basis.
The objective approach is even more dominant and forms part of the medical
model approach to madness. In this approach, John’s belief that he is mad would be
dismissed if on a clinical diagnostic interview none or insufficient numbers of specific
symptoms were deemed to be present to warrant a diagnostic label. At least some
psychiatrists would be tempted to dismiss John’s belief in his “madness” as simply
that of the “worried well.” Equally, Tom’s belief that despite hearing voices he isn’t
mad would be likely to be deemed a “lack of insight” and therefore one of the present-
ing symptoms for the objective conclusion that he exceeded the threshold on a range
of symptoms in a clinical diagnostic interview.
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Before anyone thinks that the problem of madness is merely that of a resolution of
subjective versus objective standpoints, French philosophy, especially the provoca-
tive work of Michel Foucault, has presented an alternative middle way that cocks a
snook at our simplified subjective versus objective descriptors. Again, let us take two
examples in an attempt to highlight what the issues are:
Carol believes that she is mad, society believes that she is mad, but she isn’t.
Jane believes that she is not mad, society believes that she is mad, but she isn’t.
There are of course further possible combinations that can be added to these two
examples, but the core of what they attempt to capture is the social constructionist
possibility that madness is a societal construct that overrides the individual’s beliefs,
no matter what those beliefs are. Constructionists such as Mary Boyle (2013) would
argue that the subjective approach of the clinical psychologist already outlined is
wrong because it is individualistic and ignores the role of social construction, and
that the objective medical model of psychiatry is pseudoscientific and reductionist
because it reduces social–psychological phenomena to biological mechanisms. Stig-
matization of different groups has occurred throughout history, and the “mad” rep-
resent a socially constructed stigmatized group that has been targeted in our recent
industrial and post-industrial ages. However, social constructionists such as Mary
Boyle miss the possibility that construction also occurs at an individual intrapsychic
level because they reject the individual psychological level of explanation. Individual
cognitive constructive processes (e.g., Neisser, 1976) must be considered alongside
social constructive processes to cover at least the following category of possible
models:
Sergei believes that he is mad, but society believes that he is not mad.
In this example, Sergei has a personal construction that he is mad, whereas society
does not believe him to be mad. Any constructionist approach to madness therefore
needs to allow for inconsistent and contradictory constructions between the psycho-
logical and social levels, in addition to contradictory constructions within each level
that, for example, would allow for state-dependent models of the form:
On Mondays Victor believes he is mad, but for the rest of the week he believes that he
is not mad.
While anxious, Jeremy believes he is mad, but not when he is feeling happy.
The general situation represented by the subjective, the objective, and the con-
structionist approaches may seem as irresolvable as the conflicts between the three
great monotheisms of Judaism, Christianity, and Islam. And just as pointing to the
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preface
Bible as the shared book of the three monotheisms is likely to annoy all and satisfy
none, perhaps there is a meta-level at which the subjective, objective, and construc-
tionist viewpoints all say something important about madness:
What if John’s subjective belief that he is mad is important?
What if Tom’s belief that he isn’t mad is mistaken, that it is a false belief?
And what if society does construct stigmatized groups, of which madness is a cur-
rent historical example?
That is, what if the concept of madness has to be understood as the interplay between
all of these possible approaches, because no one approach is absolutely right, but
equally no one approach is absolutely wrong. Each approach describes a different
part of the mad elephant in the dark room, as it were.
Now tough-minded proponents of each of these three approaches will lay into
such a proposal as morally and philosophically bankrupt, inconsistent, and contra-
dictory. However, what the approach actually attempts is an integration across sev-
eral levels of explanation, including the biological, the psychological, and the social,
which proposes that understanding at one level cannot and should not be reduced
to understanding at a lower level; nevertheless, effects permeate across the levels,
though not in simple one-to-one mapping rules. Madness therefore is a construc-
tion, by the individual, by society, or by both, of a set of biopsychosocial presenting
problems, but these constructions cannot simply be reduced to a set of biological
signs and symptoms, in contrast to the standard medical model for physical illnesses
which can be understood at a purely biomedical level. At best, the solution might be
to use a “majority report” in which at least two of the systems agree on “madness”
even if the third does not, as we will argue later in the book.
Let us return to Tom, who is hearing voices. A clinical diagnostic interview admin-
istered by a psychiatrist deems Tom to be suffering from schizophrenia with a lack of
insight into his disorder. He is therefore prescribed medication against his will and
put under section for further observation because he represents a potential danger
to society. Cases such as Tom’s highlight the conflict between the objective (medical
model) and constructionist approaches. The stigmatization of Tom as dangerous and
lacking insight leads to a social construction, which may be as inappropriate in its
application to Tom as it is to the average person on the Clapham Omnibus. Social
control of “madness” quite rightly becomes the focus of the conflict in such cases.
OK. Let’s imagine that the Wizard of Oz has just waved his wand and we have turned
into a perfectly tolerant and perfectly supportive society. There are no stigmatized
groups and everyone is given the best possible care when they suffer or experience
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