Can people diagnosed as chronically mentally ill speak?
Michael May, RheinMain University of Applied Sciences
1 By way of introduction: On consensus and those who live outside it
In his novel Where you come from, Saša Stanišić describes Huso, who lived in his hometown of Višegrad as “an unemployed drunk” (2019, p. 9) in a “house of planks and cardboard” (ibid.):
“[W]e […], the children, laughed at him for being scrawny and having holes in his boots and gaps in his teeth. A crazy man, I thought at the time; today I think he just lived his life without paying attention to the consensus about things like where to sleep, how to dress, how to pronounce words clearly, and the condition your teeth were supposed to find themselves in” (ibid.).
The consensus referred to by Stanišić can be further interpreted, following Gramsci, as “the instrument of government of the ruling classes to hold the consensus and exercise hegemony over subaltern groups” (1994, p. 1325). Accordingly, people who have been diagnosed with a mental and behavioural disorder on the basis of diagnostic systems such as the ICD-10[1], or, as in the DSM-5, a mental disorder as a syndrome, which is defined in these diagnostic systems as clinically significant disorders of a person's cognitions, emotion regulation, and behaviour (Falkai et al. 2020, p. 26f.), can also be regarded as subalterns.
The operationalization of the so-called ‘disorders’ systematized in these inventories on the basis of certain accumulations of symptoms is also based on a consensus agreed upon by those responsible in the relevant specialist community. Which cognitive and habitual representations of mental experience are considered to be ‘disturbed’ is undergoing changes that can hardly be regarded as scientific progress. On the contrary, prominent figures such as the former chairman of the DSM-4 commission and international professional associations have issued a statement of concern that accuses the new version of insufficient reliability and validity (Jacobi et al. 2013, p. 2364).
The fact that it is a substantial expansion of the listed ‘disorders’ that is the most striking feature of the changes, the number of which has more than doubled since the introduction of the DSM and which is also problematized in the aforementioned statement of concern in connection with an excessive psychiatrization or medicalization (ibid.), is likely to be largely related to the high level of financial support for its participants on the part of the pharmaceutical industry: 69% overall, 83% in the working group “affective disorders” 100% in the working group “sleep disorders” (Cosgrove & Krimsky 2012). When Jacobi et al. (2013, p. 2368) point out with regard to this criticism in the statement of concern that it is ultimately more a social than a scientific question, as to what priority is given to the promotion of mental health and the prevention and treatment of mental disorders, they surely did not have these financial entanglements of commission members with the pharmaceutical industry in mind.
Moreover, their argument, which at first glance seems very plausible, must be relativized against the background of Gramsci's reflections on hegemony theory regarding the significant influence of science on the creation and maintenance of hegemony. This concerns not only the protection of the interests of the pharmaceutical industry by means of the scientists it funds in the commissions that agree on (new) disorders and their operationalization in official diagnostic inventories such as the DSM-5. On the contrary, such scientific constructions of ‘disorders’ can most certainly be related to more general societal efforts of ruling classes to exercise hegemony over subaltern groups (Gramsci 1994, p. 1325). This will be briefly reconstructed below, using Foucault´s (2020a) History of Madness as an example.
2 An interpretation of Foucault's History of Madness in terms of hegemony theory
2.1 The design of Foucault's study
With regard to an interpretation of Foucault´s Madness and Civilization in terms of hegemony theory, it should first be noted that therein, Foucault unlike in his later writings presents himself less as a historian than as a philosopher who attempts to turn Hegel´s philosophy of reason on its head (Geisenhanslüke 2020, p. 32). Foucault explicitly positions himself against dialectics, in contrast to Engels, who penned the phrase, referring to Hegel´s dialectics of concepts turned off its head, on which it was standing, and placed upon its feet (1975, p. 293) with regard to his project to establish a materialistic or naturalistic foundation of dialectics, which was pursued in collaboration with Marx in a division of labour, but which was not completed by either of them[2].
In his book, Foucault contrasts Hegel´s dialectical history of reason with the tragic history of madness (Geisenhanslüke 2020, p. 28) by confronting the dialectic of history with the immobile structures of tragedy (Foucault 2020a, p. 11). In contrast to the monologue of reason about madness (ibid., p. 8), he is concerned with an archaeology of that silence (ibid.), within which the tragic becomes a form of counter-memory to the history of reason (Geisenhanslüke 2020, p. 27). In contrast to the dialectic of history as (re)constructed by Hegel as one of self-realizing reason, Foucault´s (2020a, p. 14) archaeology thus aims at the point where history is immobilized in the tragic, in order to elaborate, in returning to that origin, the moment at which madness is an undifferentiated experience, a not yet divided experience of division itself (ibid., p. 7).
Foucault postulates that in this most general and concrete form, for those who from the very beginning reject any appropriation of madness by science (ibid., p. 11), it is experienced as nothing more than an absence d´oeuvre. Geisenhanslüke (2020, p. 27) criticizes that this has been translated in the German edition as the absence of work (Foucault 2020a, p. 11), which is reminiscent of Stanišić´s Huso. Geisenhanslüke (2020, p. 27) sees this term as being more than the absence of work and interprets Foucault´s experiential concept of madness, which refers to its immediate and yet scientifically unverifiable form, as a formless void and nothingness as well as an empty negativity of reason, a negativity, however, that at the same time populates itself with distinct forms of madness (ibid, p. 32).
This is understandable not only in light of Foucault´s outlined philosophical project of an “anti-Hegel”, as it were, but also insofar as he sees what he calls the critical consciousness of madness becoming hegemonic in the transition from the Renaissance to the classical age, that unreason becomes the cause of reason, to the extent that reason recognizes it only insofar as it possesses it (Foucault 2020a, p. 351). For Foucault, in relation to reason madness now had a double mode: it was at once on the other side, and offered to its gaze (ibid., p. 177). At the same time, he (ibid., p. 49) sees the tragic figures of madness driven more and more into the shadows.
2.2 On the silencing of madness in the context of original accumulation
Alongside this critical awareness, Foucault also sees a practical consciousness of madness, invoking the difference between madness and reason, in the form of – to use Gramscian terms – increasingly hegemonic norms of the ruling classes. This practical consciousness of madness seeks – hegemony protected by the armour of coercion (Gramsci 1994, 783) – to silence madness by means of internment. It thus prevents what Foucault calls an enunciative consciousness of madness based on the possibility of calling madness by its name (Geisenhanslüke 2020, p. 30). When, against this background, he characterizes the specific experience of madness in the classical age as the impossibility of finding one´s own language of madness outside of silence and internment (ibid., p. 31), this however points to a concept of subalternity as understood by Spivak (2008b, p. 127) not solely as the inability to make oneself heard, because the act of speaking is only complete through speaking and hearing. Beyond that, there is for her something of a non-speaking nature inherent in the very concept of subalternity (ibid., p. 121). It is indeed the title of her essay, “Can the Subaltern speak?” that I reference in the title of this paper.
To return to the issue of the translation of Foucault´s version of the experience of madness as an absence d'oeuvre, it must, however, be noted that Foucault (2020a, p. 80), on the other hand, elaborates how this increasing internment of those considered insane went hand in hand with forced labour, resulting from a general economic crisis that affected all of seventeenth-century Europe. According to Brieler (2020, p. 191), Foucault´s great imprisonment (Foucault 2020a, p. 68) should be read as the central historical chapter of his “structural investigation of the whole of history” (ibid., p. 13) in Madness and Civilization as an often overlooked parallel history of the original accumulation in Marx´ Capital. Here, Foucault (ibid., p. 89) already shows how this internment contributed to producing a certain ethical consciousness of labour. As Brieler (2020, p. 191) shows, the section missing from the German translation, “Le monde correctionaire” (Folie et déraison 1961, 97-134) supports this interpretation more clearly. Even Geisenhanslüke (2020, p. 30) concedes with regard to Foucault´s interpretation of the internment of the insane that although economically a failure, the repression and the usefulness of insanity went hand in hand.
Continuing, Brieler (2020, p. 192) sees Foucault´s original contribution to the genesis of capitalism as a parallel history to Marx´s original accumulation in Foucault´s 1973 lecture, The Punitive Society, as well as in his book Discipline and Punish, which should be read as complementary to the first volume of Marx´s Capital. Foucault´s lecture already addresses how physical strength is transformed into manpower and this manpower is integrated into a system of production that turns it into a productive resource. In the book, Foucault (2014, p. 283) then not only substantiates that the two processes, accumulation of human beings and accumulation of capital, cannot be separated, but furthermore shows how, since the 19th century, the character and form of punishment fundamentally changed, in that physical forms of punishment were increasingly replaced by those impacting the newly discovered soul. In the process, medicine, psychology, education, welfare, social work assumed more and more powers of control and sanction (ibid., p. 395). Since all these institutions, now expanding and working in a completely novel way, used the same means of disciplinary training, Foucault sees the emergence of a unified strategy, which he calls disciplinary power.
Whereas in this book he was concerned with a political anatomy (ibid., p. 42) of this power, in The Will to Knowledge Foucault (1991, p. 168) consistently pursues the process of the alignment of human accumulation with capital accumulation as an analytics (ibid., p. 102) of its capacity to produce docile bodies and useful individuals, by not only modelling but generating norms and discipline. Alongside disciplinary power as a political anatomy of bodies, a positive life power or – as Foucault (1991, p. 171) also calls it – biopower had thus emerged to organize the living in a realm of value and utility.
For Foucault (ibid., p. 168), this biopower is certainly an indispensable element in the development of capitalism. He (1978, p. 91ff.) sees it as one of the great inventions of bourgeois society, as well as one of its preconditions. In contrast to feudalism, in which the rule of the sovereign had been absolute law, the order and functioning of bourgeois society was based on psychologically and physically internalized norms. The old code of law was increasingly being replaced by the rule of the new power of the natural norm in the form of a code of normalization. In this respect, Foucault speaks of a society of normalization, which, however, is defined through and through by the mechanisms of disciplinary coercion.
However, consent to the forms of circulation of bourgeois society and its functional values no longer had to be forced through elaborate procedures of violence, since the new methods aiming at internalisation and still to be explained in more detail were at the same time much more effective and less costly. In the process, the form of scientific discourse and the institutions that produce it (ibid., p. 52) would become the means of conveyance of modern power, since the new code of normalization (ibid., p. 93) referred to a theoretical horizon formed by the field of human science. Its jurisdiction is that of a clinical knowledge. As Foucault (1991, p. 89) describes, this slowly developed over the course of several centuries as a knowledge of the subject; not so much a knowledge of its form, but of that which divides it, that which possibly determines it, but above all of that which always remains elusive to itself.
2.3 On the treatment of madness emerging within the framework of a new power-knowledge-dispositif and its framing in terms of hegemony theory
According to Foucault (1991, p. 77ff.), this knowledge was produced by the subject through methodical examination procedures that developed from the medieval practice of confession, examination of conscience, and the Inquisition. Not only people´s behaviour would be probed in this way, but also their conscience, their soul, their individuality. Foucault assumes that this questioning not only leads to confessions, but at the same time allows the corresponding results to become social reality. Foucault thus sees a power-knowledge-dispositif emerging, which forms subjects according to a normative truth, which is then expressed as a classificatory one, as is still reflected today in the diagnostic instruments mentioned earlier. Foucault´s (1978, p. 119ff.) concept of dispositif thus focuses on strategies of power relations that support and are supported by types of knowledge as a decidedly heterogeneous ensemble that includes discourses, institutions, architectural settings, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral, or philanthropic tenets.
In this context, he then also sees an analytical consciousness of madness emerging, which shifts the command over madness solely to the authority of the physician (Geisenhanslüke 2020, p. 33). Whereas in the classical age internment, prisons, dungeons, and even punishments still established a silent dialogue between reason and unreason, as a battle, Foucault (2020a, p. 520) sees this dialogue dissolving in this process. Unreason and madness, which were still secretly connected to one another in the classical age (Geisenhanslüke, 2020, p. 33), were finally separated from one another for good. Furthermore, this was accompanied by a differentiation between the physical and the moral (ibid., p. 32). To the extent that the attention directed to the disorders of the mind now conceives of madness as the psychological effect of a moral fault (Foucault 2020a, p. 306), it is now morality and not medicine that determines the manifestations of madness and thus at the same time opens up the field that nineteenth-century psychiatry then occupied (Geisenhanslüke 2020, p. 32).
Foucault also sees the emergence of psychoanalysis as part of a dispositif of surveillance that is no longer constructed to tower over the patient in the medium of the gaze alone, but beyond that in the medium of language (Geisenhanslüke 2020, p. 33). Madness thereby “now spoke an anthropological language: denoting, in an equivocal process that gave it its worrying power for the modern world, the truth of man and the loss of that truth, and consequently, the truth of this truth.” (Foucault 2009, p. 557).
With the development of such a dispositif, Foucault thus sees a change in the meaning of madness, which “from that point on […] no longer indicated a certain relation between men and the truth” (ibid.) which, “silently at least, always implied freedom” (ibid.); but merely “a relationship between man and his own truth” (ibid.). Accordingly, Foucault also interprets the liberation of the mentally ill from their chains through the creation of asylums reserved exclusively for them, in which they are no longer imprisoned, as part of this dispositif.
Foucault (2006) coined the term heterotopia of deviation for these asylums in order to analyse their institutional structures as intersections and sites of transmission in their twofold spatial relationality as spaces of enclosing exclusion. His analysis of how the internal boundaries, power relations, functions and systems of norms not only point to socially constructed normalities, but are also structured by the practice of the state and how the order and organization of the institution and its practices are linked to political knowledge, power and strategy via power relations (Diebäcker 2014, p. 112) follows Gramsci not only in terms of hegemony theory. It also reinforces his theory that any hegemonic relationship necessarily involves a pedagogical relationship (Gramsci 1994, p. 1335).
However, Foucault (1978, p. 82) does not consider power as domination of one group over another, of one class over another. Rather, he sees it as functioning by means of a net-like organization with corresponding dispositif as connecting points, in the meshes of which the individuals not only circulate but in which they are formed as subjects, constantly in a position in which they simultaneously experience and exercise this power. He does join company with Nietzsche[3] when he tries to capture this in the paradoxical metaphor of a productive war (Foucault 1991, p. 113ff.). However, when he uses this metaphor of war to express that this power utilizes the potential tensions already present in society in order to merely force them to take a certain direction, astonishing parallels to Gramsci (1994) become apparent, who also uses such a vocabulary in his analysis of the creation and maintenance of hegemony.
However, while for Foucault (1991, p. 114) power is not a structure, not a power of a powerful few, but only the name one gives to a complex strategic situation, for Gramsci the societa politica, under which he subsumes parliament, jurisprudence, government, police, and military, and the societa civile of bourgeois society, with educational institutions, churches, associations, trade unions, and mass media, constitute two great superstructural levels (Gramsci 1994, p. 1502). Following Marx, he (ibid., p. 1045) analyses it as a complex and discordant ensemble, that reflects the ensemble of the social relations of production. For Gramsci (ibid., p. 2069), hegemony originates in the factory and requires only a minimal number of professional mediators of politics and ideology to exercise it. At the same time, however, he leaves no doubt that
“the fact of hegemony presupposes that the interests and tendencies of those groups over whom hegemony is exercised have been taken into account and that a certain equilibrium is established. It presupposes, in other words, that the hegemonic group should make sacrifices of an economic-corporate kind; these sacrifices, however, cannot touch the essential; since hegemony is political but also and above all economic, it has its material base in the decisive function exercised by the hegemonic group in the decisive core of economic activity” (Gramsci 2011, p. 195).
3 Alienation and the subalternity of those diagnosed as ’mentally ill’
The subalternity, in Gramsci’s sense (1994, p. 2194f. ), of those today no longer diagnosed as ‘mentally ill’ but as ‘having mental health issues’ is revealed by the fact that they are, at one and the same time, both integrated into the socially dominant hegemony and at the same time excluded from the forms of representation characteristic thereof, due to the diverse institutions of (community) psychiatry in the form of special types of (sheltered) housing, workshops and day care centres, which can be understood as heterotopias in Foucault´s sense, and between which they are processed[4] by the professionals. Foucault concedes with regard to madness, condemned as it is to subalternity in the sense of Spivak, that after the long silence of the classical age, it found its voice once more (Foucault 2020, p. 544) in the transition to modernity:
“But this was a language pregnant with a new significance: the old tragic discourses of the Renaissance, which had spoken of a tear in the fabric of the world, the end of time, and man devoured by his animality, were forgotten. This language of madness was reborn, but as a lyrical explosion” (Foucault 2009., p. 559).
In this form of enunciative awareness he even sees the possibility of a recognition of madness in the mirror of reason (Geisenhanslüke 2020, p. 31). However, this ability to overcome subalternity remains reserved for poets, such as Hölderlin, or philosophers, such as Nietzsche, whom Foucault names as an example, among others. By contrast, those who are now processed within the heterotopias of (community) psychiatry continue to be subjected to a form of subalternity as speechlessness – and not only those who are diagnosed with mutism and aphasia. It is, in fact, only in exceptional cases that this group succeeds in making its voice heard (Spivak 2008b, p. 127) in society with its experiences. Even among the professionals responsible for them, this is rarely the case.
Moreover, those who were/are diagnosed with ‘mental illness’ in the past and ‘having mental health issues’ today are also robbed of their own language by what Foucault, in his dissertation[5] and its revised version (Foucault 2017), calls psychological alienation, which he distinguishes from alienation in the historical sense[6]. As an expression of the latter, Foucault links the ‘mentally ill’, which in the course of the modern age became a sujet de scandale, to the inconsistencies of the bourgeois revolution with regard to their stagnating at a point of theoretical freedom and abstract equality (Gondek 2020, p. 16). With his concept of psychological alienation, he emphasizes that the label ‘mentally ill’ now conceals alienated madness, alienated into the very psychology that madness itself made possible (Foucault 2017, p. 116).
Foucault (ibid.) contrasts this with liberated and disalienated madness, returned, as it were, to its original language, which will be explored in more detail in a moment. However, even elementary affective manifestations of life are alienated by clinical psychology and the way in which so-called pathological disorders or changes affecting thinking, mood, feelings, memory, behaviour, experience or impulse[7] are diagnosed and treated within the framework of psychiatry. Thus, the observations gathered by our practice research network VISION-RA show almost on a regular basis that especially among those who have been diagnosed with a chronic mental illness in the area of mood or personality disorders as well as psychoses, any even slightly expressive manifestation of feelings is interpreted not only by professionals of (community) psychiatry, but also by the users of mental health services themselves as symptoms of this illness. This is the case even if we researchers consider these expressions of emotion by users of mental health services to be an appropriate response to the specific situation.
Accordingly, Laing (1994, p. 33) also states that the typical psychiatric patient is a function of the typical psychiatrist and the typical psychiatric hospital. And similarly to Foucault, Laing (2015, p. 22) also assumes that the label ‘perverse’ or ‘mad’ merely attaches a label to forms of alienation that lie beyond the prevailing norm of alienation. For, similarly to what Foucault calls historical alienation, Laing also sees the – as Gramsci would put it – inclusion in the hegemonic consensus of ‘normality’ as going hand in hand with alienation. This he seeks to characterize with psychoanalytic categories as a product of repression, denial, isolation, projection, introjection, and other destructive actions undertaken to counter experience (ibid., p. 21). However, he sees this alienation as being caused primarily by the physical and/or psychological use of violence by people against people (ibid., p. 10).
When Laing (ibid., p. 116f.) demands instead of the degrading ceremony of psychiatric examination, diagnosis, and prognosis an initiation ceremony[8] for those who are ready (often, in psychiatric terminology, those who are on the way to a schizophrenic breakdown), in which they are guided, with full social approval and support, into their own inner space and time by people who have already been there and returned, and provocatively characterizes this as ex-patients[9] helping future patients to go mad, this seems at first glance to be heading towards something similar to Foucault´s (2017, p. 116) liberated and disalienated madness, returned, as it were, to its original language. In contrast, Laing´s existential phenomenology, which focuses on the nature of a person´s experience of his world and himself (1994, p. 19), is concerned with learning from the individual himself the history of his self, because only through this and not what a psychiatric anamnesis usually is under these circumstances, namely the history of the false-self system, does his psychosis become explicable (ibid., p. 182).
4 On the approach of the practical research network VISION-RA
4.1 On the concept of disalienation in VISION-RA
In VISION-RA, we are interested in how people who have experienced crises and users of mental health services seek to protect their inner self – as Laing calls it – also by means of what is then diagnosed as a severe mental ‘disorder’. And in a sense, we are also striving in this regard to achieve – in Foucault´s words – disalienation. However, this seems to us to be possible only on a momentary basis and in relationships. We focus in particular on the relationships to the professionals in the field of (community) psychiatry. Above all, with our work in VISION-RA, we want to promote and strengthen transactional affective coordination processes between them, which cannot be brought about arbitrarily, but which can be promoted by corresponding experiences, in which a specific recognition of the subjective reality of the other (Stern et al. 2012, p. 56) takes place through the fact that both partners share an experience with each other and implicitly know of this commonality (Stern 2005, p. 175).
This experience with an Other that takes place or is actually lived through in the present, is not so much a conscious awareness but rather an impression of congruity (ibid, p. 178) with respect to what is happening now, between the two of them and is ratified by complementary and coordinated actions of intersubjective acknowledgement or recognition (Stern et al. 2012, p. 56). Due to the fact that this nonverbal alignment occurs so synchronously that it is hardly possible to determine from whom the impulse originated, Stern et al. in their microanalytic examination of psychodynamic psychotherapy processes speak in this regard of a moment of meeting. Conceived by them as a real relationship in the form of an intersubjective field that characterizes an authentic personal engagement as well as reasonably accurate perceptions of current “ways of being-with-the-other” (ibid., p. 55), overcoming alienation seems to us to be possible in such moments of meeting, at least on a situational basis. Our aim is to promote this, as will be discussed later, in the form of an enlightenment which encompasses the relationship itself (Negt & Kluge 1981, p. 988) and changes it in such a way that both parties – professionals as well as users of mental health services – gain a greater degree of freedom in their (joint) actions (May 2022).
Not only in light of the fact that relationships are embedded in attitudes (Negt & Kluge 1981, p. 986) and therefore an enlightenment that encompasses the relationship itself must consist not of talk, but of attitudes, when it expresses itself in a way that is particular to the language of the relationship (ibid, p. 988), we do not share Foucault´s (2017, p. 116) postulate of an original language of what he – as outlined above – understands as an anti-Hegelian concept of madness. In Mental Illness and Psychology, he had already defined madness as very general and original experiences on the basis of which more articulated experiences and above all evaluations are formed, which then, according to Gondek (2020, p. 17), were mistakenly translated in the German edition as “fundamental experiences” (Foucault 2017, p. 118).
If Foucault's concept of madness thus adheres to a definitive relation of man to himself, which precedes all his historical experiences and relativizes them by measuring them against his own fundamental truth (Gondek 2020, p. 17), this also has nothing to do with the true inner self to which Laing refers. If in this respect Laing (1994, p. 196) considers it necessary in the therapeutic context to make contact with the original self of the individual, which, he believes, is still a possibility if not a reality, and which can still be healed back to a possible life, the concept of recovery taken up in the title of our research association also tries to express this. It must be pointed out, however, with Honneth (2015, p. 87), that a human subject, in order to be able to perceive itself as such, must be capable of affirming itself in an expressive self-relationship to the extent that he regards his own psychic experiences as worthy of being actively disclosed and articulated.
4.2 On the connection between VISION-RA and Lorenzer´s theory of interaction forms
Much like Laing (1994), who directly draws on Heidegger´s concept of being-in-the-world, Honneth (2015, p. 40ff.), referring to the latter, also sees this expressive self-relationship as being preceded by a primordial form of relating to the world, which he analyses from a purely ontogenetic perspective to the effect that, to take care to maintain a fluent interaction with our surroundings all elements of a given situation are qualitatively disclosed to us from a perspective of engaged involvement. Honneth (ibid., p. 42) thus focuses on an attitude of recognition in which the recognition of the qualitative significance that other persons or things have for our mode of existence is expressed, and which is also a prerequisite for the enlightenment of the relationship between professionals and users of mental health services, which we strive for in VISION-RA. Against this background, Honneth (ibid., p. 61) then postulates that there is in human social behaviour a priority, simultaneously genetic and categorial, of recognition over cognition.
However, Foucault and Honneth disregard the fact that even for such very general and primordial experiences, which not only formed the basis of more articulated ones, but allegedly preceded all historical experiences, as Marx (1961, p. 637) postulates, society as a subject is given. Marx, of course, understands subject here in the Aristotelian sense as something underlying, which does not necessarily have to possess an intentional structure. In Lorenzer´s (1972) theory of interaction forms, which we reference in VISION-RA, this prior nature of society is taken into account.
According to his theory, linguistic-symbolic interaction forms are preceded by sensual-symbolic interaction forms and these, again, by sensual-immediate interaction forms. In contrast to Honneth´s genetic primacy of recognition, Lorenzer sees the latter as determined interaction forms already beginning in the womb. When Foucault (2020a, p. 7) defines madness as undifferentiated experience, the still undivided experience of the division itself, which supposedly precedes all subsequent more articulated differentiations, this can be demystified with Lorenzer´s concept of specific interaction forms. Moreover, Lorenzer assumes that this relationship between mother and foetus, which he calls interaction, is already being formed[10] by interpretations, scientific findings, and practices of how pregnancy is socially framed and thus experienced by mothers in a specific cultural context. The same applies to birth practices and those processes in which, prior to any symbolic or linguistic representation, the infant´s relations to the world and to itself are formed through sensual-immediate interaction forms as primordial affective experiences not immediately accessible to consciousness. These form the foundations and persist even when more articulate experiences emerge in the form of first sensual-symbolic (facial expressions, gestures, emotionally significant rituals) and later also linguistic-symbolic interaction forms.
According to Lorenzer, what is then diagnosed today as ‘severe mental disorders’ by psychiatry and claimed as its very own field of competence, has its origin in traumatic experiences in early childhood which were experienced as an existential threat. Similarly, Laing (1994, p. 94) has suggested that the schizoid state can be understood as an attempt to preserve a being that is precariously structured. According to his existential phenomenology (ibid., p. 19), an individual diagnosed accordingly therefore fears a real live dialectical relationship with real live people, because his autonomy is threatened with engulfment and he therefore has to guard himself against losing his subjectivity and sense of being alive.
Lorenzer further assumes that existential experiences of violence, not only those in early childhood, but also later ones, referred to as trauma, elude the consciousness[11] and thus linguistic symbolization, and are ‘only’ able to articulate themselves in sensual-immediate, as well as overlying sensual-symbolic interaction forms. What Lorenzer (1995) has thus termed the destruction of language requires, in order to overcome the subalternity of the sensual experiences of suffering that seeks resolution (Lorenzer 1973, p. 142), and which is able to express itself only in the language of sensual-immediate and sensual-symbolic interaction forms, a scenic understanding (Lorenzer 2006b) on the part of the professionals, in order to decode the latent contents in these interaction forms that point to this sensual experience of suffering.
4.3 On the methodology of VISION-RA
In VISION-RA we do not limit ourselves to a scenic understanding within the framework of the research group, in which we also involve students. Instead, we invite the users of mental health services and professionals, whose (affective) coordination processes we have observed and sought to understand scenically, to reconstruct the corresponding interaction sequences together with us. In this process, we draw on the dialogical-dialectical principle of encoding/decoding developed by Paulo Freire (1975, p. 87ff.). This enables us to overcome Spivak´s dilemma, according to which it would be downright cynical to say that users of mental health services can speak for themselves[12], because – as outlined above – often not even the professionals are interested in their experience, let alone any possibility that they could see themselves, with their life experiences and plans, as being represented in this society. On the other hand, however, speaking out on their behalf, which is undoubtedly necessary in terms of social and health policy – e.g., if we researchers or professionals in the field of (community) psychiatry do so – implicitly contributes to depriving them of their own language.
Freire does not use the term subalternity. However, his pedagogy of the oppressed, with its dialogical/dialectical principle of encoding/decoding, also originates from an analysis of what he calls the culture of silence. He seeks to overcome this by a process of decoding the limit situations experienced by those affected, which have been iconographical coded by researchers in the form of pictures, photos, dramatized scenes – i.e. in the form of sensual-symbolic interaction forms – in which they as the oppressed – and, as I am attempting to show in this paper, this would also, in a sense, include users of mental health services – gradually become aware of the fact that they are being blocked or dis-abled[13] in the realization of their human subjectivity.
In VISION-RA, we focus on sensory-symbolic interaction forms in the form of various methods of psychodrama, which we combine with those of Boal´s (2009) Theatre of the Oppressed (May 2017), when coding the scenes, we observe. Of particular importance for us in this context is the technique of doubling, which comes from depth psychology-based psychodrama. With the consent of all those participating in the joint reconstruction, we offer them, by putting ourselves in their position, hypotheses in first-person form about latent (affective) contents that we have gathered in the scenic understanding to be decoded. For this purpose, we use metaphorical wording rich in imagery, which Lorenzer (2006a) assigns to the sensual-symbolic interaction forms due to their manifold, resonating, affective connotations – in contrast to the linguistic-symbolic interaction forms aiming at precise denotations. This allows the participants to develop their own language during the decoding process in order to express their highly subjective experience. In the majority of cases, we succeed in this way, that they, as a consequence – above all, however, because they experience themselves, by being referenced and doubled by us as being recognized in the Honnethian (2015, p. 87) sense – now also consider their own psychic experiences as worthy of being actively disclosed and articulated. Unfortunately, far more moments of meeting have taken place between us researchers and the users of mental health services than between them and the professionals as a result of this doubling in our joint reconstruction work to date.
Due to coronavirus precautions, which, with the exception of doubling, have also placed tight constraints on our experimentation with other methods of psychodrama, we have not yet been able to test other forms of coding. However, we hope to soon be able to film scenes of interaction between users of mental health services and professionals using several cameras, in order to then present to them moments we have identified during scenic understanding to be decoded in such a way that a medium long shot can be seen in the middle, and, at the same time, close-ups of the participants’ facial expressions in the top right and left-hand corners and their gestures at the bottom. By means of corresponding maieutic questioning, we thus aim to open up a space in the process of decoding also for the users of mental health services, which not only enables them to find their own language for their experience. Instead of postulating, like Foucault (2017, p. 116) an original language of madness, we are instead interested in these joint reconstructions, similarly to Laing in his existential phenomenology, which is also strictly dialog-oriented following Buber, in searching for a language within the framework of a joint interactive practice in order to understand the “unheard messages of the current symptoms” as well as to expand the boundaries of the present emancipatory conceptual and discursive framework (Krüger-Kirn 2013, p. 413), in order to overcome their subalternity in this way. Moreover, we aim to enable the users of mental health services – and have largely succeeded in doing in the joint reconstructions carried out thus far – to tentatively explore their own objectives and thus not to merely observe or even manipulate them (Honneth 2015, p. 89).
5 VISION-RA´s findings on reifying interaction forms in (community) psychiatry
Forms of observation and manipulation of one´s own objectives, analysed by Honneth as reifying, are documented in abundance in our data material, especially in connection with the evaluative logic of participation planning. Since participation planning in Germany is the legal basis for people in need of support to be able to access professional support at all, the obligation to evaluate associated with it permeates almost all the everyday interactions between users of mental health services and professionals in the field of (community) psychiatry – when a participation plan is updated, the question of whether certain everyday activities can (already) be managed by users of mental health services on their own, or to what extent they (still) need the support of specialists, is permanently up are for disposal. This is then accompanied by corresponding reifying self-observations of the users of mental health services and by a form of impression management, in which they attempt to conform to the objectives more or less imposed upon them in the context of participation planning. Against this background, Laing (1994, p. 183) has been quite sure that a not insignificant number of ‘cures’ of psychotics come from the fact that the patient has decided, for one reason or another, to pretend to be healthy once again. This has nothing to do with participation in the sense that people who have experienced crises and users of mental health services are able to see themselves represented in society with their fates and life plans, thus overcoming their subalternity, which is why the concept of participation planning seems almost cynical.
Such interaction forms or – as Honneth calls them – forms of praxis, as they are reflected in the context of the logic of participation planning in the field of (community) psychiatry, tend, from Honneth´s (2015, p. 70) perspective, toward a reification to the extent that attention to the fact of prior recognition is lost, because in the course of this praxis the purpose of observing and cognizing our surroundings asserts its independence, so to speak, to such a degree that it banishes all other situational elements to the background. In the field of (community) psychiatry, however, this purpose refers not only to the implementation of participation planning, but also to any deterioration in the so-called ‘course of the disease’ that may be emerging.
Significant in this context is Honneth´s (ibid., p. 97) theory that reification can also be a mere habitual derivative of a reifying set of convictions to the extent that the strength of such a denial of a prior recognition emanates from the content of a specific ideology. In the case of users of mental health services, however, instead of prior recognition, one should rather assume a disregard that poses a threat to their subjectivity – Laing (2015, p. 10), as outlined above, even speaks of the use of violence – as the trigger for their diagnosed ‘disorder’, their experience of which is unfortunately all too rarely recognized by professionals.
When Honneth (2015, p. 99) points out in this context that a corresponding praxis of reification finds cognitive reinforcement in reifying stereotypes, just as these typifying descriptions conversely receive motivational nourishment by serving as a suitable interpretive framework for a given kind of one-dimensional praxis, the diagnostic instruments mentioned at the beginning stand out as a prime example in connection with the subsequent practices of differential indication and intervention functioning according to the logic of subsumption in the field of (community) psychiatry. In his introductory reflections on his theory, Honneth (ibid., p. 17) himself refers to the fact that the neurophysiological perspective of the human being, which is central to biomedical psychiatry, is conceptualized as an instance of reification.
A similar case of reification occurs when the cause of specific ‘disorders’ is located in certain chemical messengers, and corresponding psychotropic drugs are then used to try to influence the release of these substances, or when a genetic disposition is alleged to be the cause, solely on the basis of an increased familial occurrence, although a corresponding gene has not yet been identified. Our data material also documents to an alarming degree further evidence of the predominance of a reifying set of convictions in the field of (community) psychiatry. Thus, the ‘disorder’, which is often diagnosed as incurable – because it is supposedly caused by genetic or neurological factors – becomes the actual subject that assaults the users of mental health services who are at its mercy. Against this background – as outlined above – each of their manifestations of life is then examined to determine whether it might be an intensifying pathology heralding a new ‘episode’. Accordingly, Laing (2015, p. 100) also discusses the problem that someone who is put into the role of the patient is usually seen as a non-actor, as a non-responsible object, is treated accordingly and even comes to see himself in this light.
6 VISION-RA´s findings on forms of resistance to reification by users of mental health services
Although psychiatry thus not only treats their illness, but they themselves are treated like objects – an inauspicious process which is then continued in the field of community psychiatric rehabilitation as part of people processing briefly described above – our data material contains cases in which people who have experienced crises and users of mental health services describe “going into” psychosis, as, for example, an active deed and reaction to a here and now that is too distressing for them. This corresponds with Laing´s (2015, p. 104) conclusion, made in the context of his social phenomenology, that without exception, experience and behaviour, when considered to be schizophrenic, constitutes a specific strategy that a person invents in order to be able to endure an intolerable situation. In some of the narratives in our material, there is evidence of a kind of transition, during which these people still seem to be conscious of this act on the one hand, but at the same time the psychotic world is already becoming more real to them, overlapping the so-called ‘normality’ of the here and now.
However, while the tendency of users of mental health services to see themselves as a non-responsible object with regard to so-called ‘episodes’ is documented very frequently in our data material, it also shows at least as frequently that they nevertheless resist the medication they are prescribed (the term says it all!). In addition, the users of mental health services confessed to us, not in joint reconstructions, but in conversations or even evaluative interviews afterwards, that they strategically used their vulnerability to such alleged ‘episodes’ by using them as an excuse to avoid having to comply with the obligations they had rather involuntarily entered into in the so-called participation planning, e.g. in the form of regular visits to day care centres or work obligations in so-called rehabilitation workshops.
Furthermore, our observation material frequently documents the strategy of changing the subject on the part of users of mental health services, not only with regard to the evaluative logic of participation planning outlined above. Although this is usually interpreted by the professionals as a symptom of their ‘disorder’, our scenic understanding points to a strong correlation of such abrupt changes of subject with situations involving shame and questions pertaining to intimate details of their lives in the course of the methodological examination procedures described by Foucault (1991, p. 77ff.). We also observed in such situations that the users of mental health services withdrew and fell silent, removing themselves from contact with the professionals. The latter, in turn, usually interpreted this as a symptom of their illness or attributed it to the fact that these people were unable to concentrate for more than a maximum of 20 minutes at a time due to their illness.
Our reconstructions together with them, however, lasted on average one hour without any such lapses in concentration. Nor do we find in their recordings any such abrupt changes of subject by the users of mental health services, nor, with one exception, any situation in which they fell silent. In this case, the user of mental health services had confessed to his specialist in the course of the reconstruction, after a corresponding doubling that I had carried out, that he initially responded to her “besieging him with care” (in vivo code) with irony, and since she did not understand this, at some point stopped saying anything at all. When the professional, taken aback by this, asked him to signal to her in future situations if it was becoming too much for him, he first became angry and said that his reactions were not that difficult to understand and subsequently fell silent. Although we normally strive in our reconstructions in the sense of Boal´s (2009, p. 241) Theatre of the Oppressed to transition from the original actual image to the ideal image, I then, as a moderator, broke off this endeavour initiated by the professional, with a wink and the words that I understood that it was now too much for him, in order to set an example.
However, the major differences demonstrated in the interaction forms of the users of mental health services as practiced by them in the working relationship of personal care services towards the professionals of community psychiatry as described above, compared to those in our reconstructions, suggest a different interpretation than the professionals´ tendency to ascribe these to their illness. Following Spivak (2008b, p. 144 f.), they can be conceived as a subaltern rebellion in the sense of a moment that distinguishes them from the general subaltern constitution, where all acts of speech exchanged in subalternity are accessible only to a discursive formation other than that of the examination, i.e., other than the diagnostic inventories commonly used in (community) psychiatry mentioned earlier.
When Fraser (1994, p. 288f.) criticizes Foucault for providing a useful description of some elements of the knowledge-producing apparatuses that contribute to an administrative redefinition of politicized needs, because it fails to include the agonal interplay between hegemonic and non-hegemonic interpretations, those tied to institutions and those not tied to institutions, it should be noted with regard to our findings concerning users of mental health services that beyond the framework that we try to open up for them in the context of our reconstructions and additionally in various workshops, they are only very rarely able to politicize their needs of their own accord due to persisting experiences of reification in the field of community psychiatry. However, interpreting those interaction forms with professionals described above, in which they in their own way reject the methodological scrutiny procedures analysed by Foucault, as a subaltern rebellion, here also offers a sensitivity for the agonal interplay between hegemonic and non-hegemonic interpretations as called for by Fraser (ibid., p. 289).
Moreover, even if it may seem to go too far, there is something to be said for interpreting the diagnosed ‘disorders’ themselves of people who have experienced crises and the users of mental health services as subaltern rebellion. Indeed, Laing (2015, p. 59) interprets schizophrenia as a successful attempt not to conform to social pseudo-reality. This corresponds to Spivak´s (2008b, p. 144 f.) characterization of what she calls subaltern rebellion as an effort to participate in representation, but not along lines defined by the official institutional representational structures, which is particularly evident in the more extroverted ‘disorders’.
Obstinacy, which also articulates itself in such ‘disorders’ as subaltern rebellion, is – as Negt/Kluge (1981, p. 766) have elaborated – not a ‘natural’ characteristic but emerges out of destitution. It is the protest against expropriation reduced to a single point, the result of the expropriation of one´s own senses that interface with the external world. This corresponds to Laing´s (1994, p. 94) interpretation of the genesis of schizophrenia as the moment at which the autonomy of the self is threatened with engulfment. When he goes on to write that it must therefore guard itself against losing his subjectivity and sense of being alive, this corresponds to Negt/Kluge´s (1981, p. 765) postulate that the motives extracted from society do not simply disappear from the overall economy of characteristics, but continue to work where they are most protected, in the subject. The obstinacy of rebellion appears, pupated as it were, in the form of the private.
Laing (1994, p. 95f.), however, points to the tragic paradox that the more the self is defended in this way, the more it is destroyed, since this shut-up self, being isolated is unable to be enriched by outer experience, and so the whole inner world comes to be more and more impoverished, until the individual may come to feel he is merely a vacuum. In its extreme form, this is then articulated in what is diagnosed as ‘catatonic schizophrenia’. It is true that in today´s society ‘depression’ is often associated with an exhausted self (Ehrenberg 2015). However, in a long-term study, people diagnosed with ‘unipolar major depression’ who exhibited increased irritability and aggression at the time they were included in the study were found to have particularly severe, complex, and chronic courses of the disorder (Judd et al. 2013). This corresponds to observations and contingency experiments in infant research with regard to the genesis of states of resignation and withdrawal, which have then also been assessed as being a predisposition for such disorders (May 2004, cap. 4.2). Even if the exhausted self is possibly rather an expression of what today´s term ‘burn-out’ attempts to differentiate from ‘depression’ in terms of diagnosis, the question also arises as to the extent to which a lack of contingency experiences may not also be an underlying factor here. The inability to achieve anything is in fact precisely the hallmark of what Spivak (2008b, p.145) calls subaltern rebellion and not being able to speak and which distinguishes it from the general subaltern constitution.
A separate study would be required to explicitly investigate this aspect. In VISION-RA, we have concentrated on focusing on those interaction forms in the working relationships between users of mental health services and professionals in which the former seek to assert and preserve their subjectivity. We then decoded these as limit acts in Freire´s sense, with which they respond to a limit situation in which they gradually become aware that they are limited in the realization of their subjectivity. We are particularly interested in situations in which such limit acts by users of mental health services result in a very acute sense that the existing intersubjective field is threatened, that an important change (for better or worse) is possible in the relationship to the professionals (Stern 2005, p. 174) and which Stern et al. refer to as a Kairos-like emotional “moment of truth” (Stern et al. 2012, p. 66). Since both participants are emotionally completely drawn into the present moment from which there is no escape, Stern et al. speak of now moments.
We are particularly interested in such now moments because they hold the potential for an enlightenment that encompasses the relationship itself (May 2022, p. 10ff.), since – as Negt/Kluge (1981, p. 989f.) have elaborated – the limit of this form of work lies in the core of the power relations that exist in a relationship, while in such now moments the forces at work in the working relationship cancel each other out. Stern et al.´s (2012, p. 68) microanalytical studies, for example, show that a new intersubjective state can emerge from a now moment that is seized and jointly recognized as such and ratified if each of the two partners contributes something unique and authentic in response to the now moment. Only a moment of meeting that develops in this way can resolve the crisis invoked by the now moment (Stern 2005, p. 175).
In our study, we found that now moments can also arise from the fact that users of mental health services externalize the inner terror they experience by way of – psychoanalytically speaking – projective identification and thus also involve the professionals in it. While there are few other examples in our observation material in which a moment of meeting resolves the crisis invoked by the now moment, in such a case no resolution of the crisis is possible at all. What seems to be required instead is affect containment, as Dornes (2000, 76ff.) reconstructs it based on findings from infant research on affect regulation, to the effect that the threatening emotion is received by the professionals in one sensory modality, who, at the same time, offer calming signals in another sensory modality.
In addition, such an ‘episode’ or emotional outburst does not come from nowhere, but can be seen coming. As outlined, the professionals have developed a particular sensitivity in this regard. However, this usually leads to an attempt to deal with the situation by pharmacological means of psychiatric treatment or even hospitalization. We were not able to explore this systematically, but in the scenic understanding of the little material available to us, it seems to be the case that what is interpreted by the professionals as symptoms of an impending ‘episode’ can be understood in general terms in the sense of Laing (1994) as reactions to a threatened self.
Instead of using the above-mentioned transition to the worlds of experience diagnosed as ‘psychotic’, which is documented in the narratives of some users of mental health services, dialogically in the sense of Laing´s (2015, p. 11) concept of social phenomenology, in order to relate as a professional my experience of the other´s behaviour to the other´s experience of my behaviour, the measures taken by the professionals seem, on the contrary, in their well-meaning but nevertheless always heteronomous character, to reinforce the experience of threat to which the users of mental health services are exposed. This is another reason to interpret their reactions to this experience of an existentially threatened self, which is unintentionally exacerbated by the assistance offered by the professionals, as a subaltern rebellion whose language is neither heard nor understood.
Contrary to our hopes, a change of attitude on the part of the professionals seems to be promoted less by our attempts at a joint reconstruction of their concrete interactions with the users of mental health services – presumably because they want to maintain their image as competent professionals in their relationship with them – than in the context of joint workshops, in which we first practice scenic understanding with them on other material involving participants unknown to them. However, for the surplus potential of meanings – that even in such forms of subaltern rebellion remain outside the figures of consciousness – not to threaten to lose its innovative capacity as an incomprehensible fantasy, as Lorenzer/Görlich (2013, p. 158) have elaborated, the tensions excluded from the public consensus must be released from the private sphere of suffering.
In VISION-RA, we try to make a modest contribution to achieving this, using maieutic methods to open up spaces, as described above, in which the life experiences and plans of people who have experienced crises and users of mental health services are recognized, first by us and then, thus mediated, also on the part of the professionals. However, their subalternity can only be overcome within the framework of a collective movement, starting from such an initially protected community, and then making themselves heard on a wider scale. The German Federal Participation Act and the practices of (community) psychiatry associated with it, however, seem to be more oriented toward integrating the users of mental health services into the hegemony than promoting efforts to achieve their representation in society.
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Author´s Address:
May, Michael Prof. Dr. phil. Habil.
Hessisches Promotionszentrum Soziale Arbeit, Hochschule RheinMain
Postfach 3251 | 65022 Wiesbaden
+49 611 9495 - 1320
michael.may@hs-rm.de
May, Michael - Hochschule RheinMain (hs-rm.de)
[2] While at least fragments of Engels´ (1962) Dialectic of Nature exist, all we know of Marx is that he would write a Dialectic after the Economy. Designed as a critique of Hegel, it was intended to be a continuation of his earlier (1843/44) attempts to follow up the critique of political economy with a critique of dialectic (Frese 2010, p. 198).
[3] The latter´s treatise Zur Genealogie der Moral (Nietzsche 2014), which focuses on the origins of bourgeois morality, ultimately also inspired the genealogical dimension of Foucault´s (1978, p. 61ff.) analysis, which is aimed at the formation of problematizations of practices and their changes, while its archaeological dimension still limited itself to the forms of problematization themselves (Foucault 2020b, p. 19).
[4] Against a background of systems theory, Stichweh (2009, p. 33) illustrates that by inclusion taking the form of people processing of the audience roles by the performance roles of the system, the institutions of inclusive exclusion (ibid., p. 41), as he seeks to reformulate Foucault´s heterotopia theorem in terms of systems theory, erect insurmountable thresholds between the realm of inclusion and the realm of exclusion, despite the good intentions they pursue, and how, to that extent, they also permanently mark with a stigma the communicative addresses they take care of as re-included addresses.
[5] See Gondek (2020) on this and its major revision for the publication on which the German translation was then based.
[6] To what extent this is a throwback to Marx´s (1990, p. 516ff.) concept of alienation cannot be discussed here due to space restrictions.
[7] https://approbatio.de/facharztrichtungen/psychiater/
[8] In this context, reference should be made to the workshops in gestalt therapy that Paul Rebillot - Wikipedia developed against the background of his own psychotic experiences and the study of rites of passage of indigenous cultures as a framework in which the participants work on their personal transformation and explore their 'shadow sides' through ritual enactments designed themselves.
[9] The model Experienced Involvement EX-IN Deutschland - Experten durch Erfahrung in der Psychiatrie (Experts through Experience in Psychiatry) also offers some approaches in this regard. However, the EX-IN recovery companions or experienced experts find themselves in the typical conflicted situation for organic intellectuals as described by Gramsci, i.e. they are able to rearticulate the experiences of the social group from which they originate but are in danger of being integrated into the hegemony through the recognition and privileges they receive from the ruling classes and then also have a corresponding effect on the group that they originally come from.
[10] Sohn-Rethel (2018, p. 137) elaborates that no school of thought can lay claim to being of dialectic critical character in which the historicity of form is not sufficiently respected or in which it is even lost altogether, as is largely the case with the French structuralists. The essential difference of Marx´s way of thinking from all other ways of thinking is that it conceives the form in which it itself transforms and develops as an inseparable part of the spatio-temporal reality of social being.
[11] Cf. my interpretation, based on self-regulation theory, of corresponding psychobiological and neurological findings in May (2004, cap. 2.3 & 3.2).
[12] Spivak (2008a) elaborates on this cynicism using the example of a conversation between Foucault and Deleuze in which they argue that subalterns can speak for themselves.
[13] This concept of disability is particularly accentuated in materialist disability pedagogy (cf. Jantzen 2016).