Tuesday 4 October 2022

On Madness: Understanding the Psychotic Mind

Today’s post is by Richard Gipps, clinical psychologist and philosopher. Richard’s psychotherapy practice is in Oxford, UK, where he also teaches some philosophy. Along with Michael Lacewing he edited The Oxford Handbook of Philosophy and Psychoanalysis (2019). 

Gipps' philosophical interests concern the nature of psychotherapeutic action, psychotic thought, and the significance of love and moral virtue for mental health. Today he writes about his new book On Madness: Understanding the Psychotic Mind (Bloomsbury 2022).

How is madness to be met with? What kind of recognition can we show, and justice can we do, to its sufferer? On hearing his fragmented and delusional discourse we’re troubled by it - not so much because we fear what he'll say or do, but because now, trying to empathically relate to them, our minds judder and the ground slips out from under our feet. On the one hand: here’s a deeply troubled human being; on the other, our mustering of ordinary humane sense-making is now severely challenged.

Confronted by this challenge, those tasked with helping the mentally ill can find themselves tempted by what On Madness describes as two characteristic evasions. One, which most bedevils biomedical psychiatry, takes refuge in the thought that, with the person in their psychosis, what we find is not so much a suffering, meaning-responsive, human being, but a currently broken mechanism. ‘Nothing to see here; medicate, watch and wait until the human subject returns to the scene’ becomes the motto. 

Such an approach voids the task of humanly relating to the psychotic subject in a more than paternalistic manner. The second, rather more characteristic of much clinical psychology, urges that what looks like broken meaning is but a surface appearance to be penetrated. ‘Discard your prejudices about madness and instead try to reach the sense-making mind behind the symptoms’ is this approach’s tagline; its corollary intellectual aim is the development of reason-retrieving resources which, when held in mind in the clinic, will enable empathic engagement to be reestablished.

Such approaches effectively privilege the significance of rationality for humane intelligibility. Either reason’s absence is taken as an invitation to adopt a merely paternalistic stance, or we’re invited to restore human contact through cleverly discerning reason’s now hidden form. On Madness takes a different tack. It asks how we may instead bear with and honour someone in her rational brokenness by taking it as an index of her overwhelm. 

Richard Gipps

The tack taken is similar to that of apophatic (or ‘negative’) theology: we come to understand God’s reality by understanding how even our most superlative attributions to Him inexorably fail to do Him justice. So too, goes the suggestion, can we come to understand the psychotic subject when we see how even our most ingenious attempts to retrieve rational order here fail to do justice to the shame, objectless dread, and brokenness which she suffers.

None of this is to say that nothing properly called understanding may be had of this subject. In truth, certain forms of intelligibility - causal explanations, phenomenological characterisations, psychodynamic motivational understanding, so-called ‘symbolic’ meaning - become all the more relevant, and sometimes only possible, once we’ve already been turned away at reason’s door. 

On Madness separates out the distinct logical forms of these modes of understanding, showing how some may yet be available whilst others are thwarted; spells out the implications of its ‘apophatic’ approach for understanding what it is to be in one’s own world (the ‘waking dream’ or ‘lost reality-testing’ of psychosis); and carefully articulates the character of delusional, confusional, and hallucinatory thought and experience. 

The book ends by considering the question of psychiatric judgement. Ought one to make one’s judgements of the psychotic subject’s delusionality and disordered thought accountable by evaluating them according to general criteria? Or might this in truth itself be an evasion of the responsibility to embody psychiatric discernment within oneself?

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