The Good, the Mad, and the Ugly: Part 1

Science & Society

May 29

The Moral Reform in Psychiatry

Codgers, bugs, crackpots, neurotics, kooks, cranks, crazies, headcases, fools, fruitcakes, tykes, sickies, deviants, nutters, loonies, lunatics, madmen, sociopaths, maniacs, obsessives, psychos, paranoids, quizzes, oddballs, schizos, wackos, lunatics, weirdos, abnormals and zanies, human creativity knows no limits when it comes to finding names for those people who are thought to be just a little bit off. But what exactly do we mean to say when we call someone mad? And what can philosophy teach us about this?

Madness is quite an important topic to reflect upon, particularly because we like to consider ourselves as its opposite: rational, normal, or healthy. If we want to understand what is normal, and how we would like to think of ourselves, we must investigate madness and abnormality.

Georg Wilhelm Friedrich Hegel is one of the most important and controversial philosophers of all time. He is known for his mind-boggling erudition, but also for his obscenely complex style, some might say bordering on insanity. Among the vast expanse of his studies he included the medical literature of his time. He greatly admired the French physician Philippe Pinel, a major figure in the ‘moral reform’ of psychiatric treatment that took off in the late 18th century.

Pinel, and Hegel after him, were critical of the tendency to reduce madness to being a physical problem and merely treating it through physical, often brutal, means. They reacted against all kinds of tortuous treatments such as electroshocks, whipping, beating, starvation, and social isolation. Hegel was on board with Pinel’s commitment to treating psychiatric patients in a more humane way. The idea was to establish a form of psycho-social care geared towards the moral reform of their patients.

A symbolic representation of the ‘moral reform’ in Psychiatry: Pinel is portrayed as freeing the mad from their shackles at the Salpêtrière hospital in Paris

Pinel and Hegel emphasized the need to understand patients, gain their confidence, and talk to them in order to address their mental distress, not simply to brand them as mad. The goal of the treatment was to instill discipline and cultivate moral behavior so that the patient could learn to cope with their world and overcome their mental distress.

Hegel’s understanding of Madness

Hegel’s main engagement with madness occurs in his Philosophy of Spirit. In the section on ‘self-feeling,’ he approaches the topic of madness or derangement. The German word he uses is: Verrücktheit, which comes from verrücken (to move or dissarange). He sees madness as a form of deranged or disarranged reason. This might already sound somewhat strange, madness as a form of reason? Hegel thought that madness is intelligible. Madness is logical, and can therefore be rationally comprehended.

Hegel thought that all madness can be understood as a form of disconnect between the self and its surrounding world, as the self withdraws further into its own isolation. We can trace such a dynamic in all kinds of mental distress. Think of an obsessive neurotic who fails to recall that he did lock the door, in fact even twice, and feels compelled to return to his home to check yet another time. Or the depressed person who is unable to keep up with social life and confines himself to his home trapping himself within his own thoughts. In more extreme cases, we can think of the psychotic person who begins hallucinating, or believes themselves to be king.

Whilst we may intuitively think that these are just problematic individuals, Hegel’s idea was that the problem of madness does not reside in the individual, but in their relation to their environment. This means that madness can be a social product: badly organized societies can make people go mad. A difficult environment can generate a whole host of mental ailments. Poverty, war, physical and sexual abuse, and bad working conditions, are all causes of mental distress which contribute towards the onset of madness.

Madness is logical, and can therefore be rationally comprehended

The disconnect between ourselves and the world is a result of our freedom; the freedom we have in the way we relate to ourselves and to the world. Our freedom enables us to do a number of things. We are able to abstract from our experience and form new representations of the world, and to act upon these representations so as to attempt to fulfill our desires and accomplish the goals we set ourselves. We are able to freely reflect upon the ways in which our particular background has determined us (such as the body we have been given, our geographical environment, the culture we grew up in, our family values) and oppose ourselves to them, or fall in line with them. We have the possibility of moulding both our own bodies and the world around us through the habits we form. However, the price we pay for this freedom is that madness forever lurks in the shadows waiting to erupt. We constantly need to ensure that we do not fall prey to madness.

A satirical depiction of the ‘science’ of phrenology premised on the idea that you could determine human psychology by measuring the shape of the skull. Hegel thought this was absurd, as does contemporary science.

We long for a certain coherency and harmony in our lives. Yet the world frequently is not able to provide the sense of security we desire. This mismatch can be discomforting and unsettling. Hegel famously characterizes history as a slaughter bench that brutally sacrifices the happiness of individuals. Madness is always a tempting resort in such a brutal and alienating world that constantly upsets our desires and lofty ideals. In an attempt to return to the fantasy of some original bliss and stability, whether it is the mother’s womb or the Garden of Eden, madness is a retreat from a harsh and rough world into ourselves.

However, since madness and rationality are not strictly separated, this attempt is destined to fail. There is always a trace of rationality that remains, and this haunts the mad. There is a contradiction between the way they see and represent themselves and the world around them, and the way they and that world actually are. However much this contradiction is repressed, it will keep resurfacing. Madness is a maladaptive coping mechanism. The mad are unable to achieve the closure they desire. Their resort to madness as a way of coping with the world is bound to fail.

the problem of madness does not reside in the individual, but resides in their relation to their environment

The mad are dominated by particular feelings, which are projected upon the world or themselves. We must be attentive to which feelings become dominant, where these feelings originate, what meaning they have, and how they affect the patient in question. As a ‘mental’ illness, madness is both a disease of the mind and the body. Causally, or to use the scientific term, etiologically, it can seem to originate both from the mind and the body. It may be treated by working on the mind, the body, or both. Contrary to what we might expect, Hegel argues that mental treatment is universal, and that physical treatment is particular to the patient. There can be no general rules for treating madness physically: that depends on the particular bodily constitution of the patient in question. However, at the psychological level the approach is always the same.

Hegel’s account of madness, as a mental disease, fits in with his broader understanding of diseases. All diseases are marked by a kind of rigidity. The normal fluid motion of an organism is interrupted as a particular part of that organism steps out of its allocated place within the whole. One part of the organism becomes fixed, preventing the coordinated movement of the whole. We can take for example a cancer tumor, which parasitically redirects the body's resources in order to fuel its own cancerous empire. This parasitic structure paralyzes and incapacitates the patient, draining its vital resources like a vampire. Likewise, the deranged fixation on false representations disconnects the mad from the world and prevents them from interacting with their environment in a healthy way.

An iconic portrait of Hegel, painted by Jakob Schlesinger in 1831

Treating the Mad

The psychological course of treatment proceeds as follows for Hegel. First off, as rational people capable of acting ethically, patients deserve to be respected and treated well. Respectful treatment is also necessary to gain the confidence of the mad. One must take care to refrain from directly attacking their pathological representations and remain open to them. The patients should not be belittled and must be approached truthfully. After winning their confidence, one must try to establish a degree of authority and make them realize that there is something important at stake. The mad feel their own weakness. They feel their own dependence on the non-mad. By learning to respect those who treat them, they are able to forcefully overcome the part of their subjectivity that stands in contradiction with actuality.

It is important to turn the mad away from their deranged thoughts towards their rational thoughts. Hegel suggests a variety of possible methods. Work as a mental and physical occupation can serve to dispel their false representations of the world, for in work they are forced to engage with the actuality of the world, which forces them out of their subjectivity. Another possibility would be to enter into their false representations in order to trick them out of their illness by resolving it in the terms of their own deranged logic.

To give a contemporary example, the neurologist Vilayanur S. Rachmachandran, developed a “mirror box” as a way to address phantom pain. Phantom pain is the pain that patients feel in lost or amputated limbs. A patient who, for instance, loses their left hand whilst clutching a grenade, may consequently experience phantom pain in the no longer existing limb. Rachmachandran found that such a patient could be cured through an ingenious use of mirrors. By setting up a mirror box so that the patient would see their right arm as if it was their left arm, Rachmachandran could address the patient’s pain by asking them to unclench their right arm. This effectively ‘tricked’ that patient into seeing themselves unclenching their left hand, which in some cases addressed their pain.

Turning back to Hegel, his treatment involves the subject coming back to terms with what is actually here. The subject needs to recognize that their own particular feelings and desires are not synonymous with the objective world outside them, that what is particular (their own feelings) must be brought in line with what is universal, with what actually is. They must recognize their idiosyncrasies as particular, and must subjugate that to the universal movement of the whole. They must recognize that their particularity must be disciplined to actuality. It is only through discipline and habit, that we can become reconciled with what is actual. This reconciliation is crucial if we want to avoid madness. Hegel argues that it is in actuality that freedom and rationality are to be found, and not in our own self-enclosed ‘inner life’. The mad, like the high-spirited youth with its lofty ideals, must be brought to recognize the rationality of the objective world and adapt to it.

However, given that madness is relational, it is crucial to note that reality may be the source of madness. This is implicit but underdeveloped in Hegel’s theory. If the way we organize ourselves collectively, the way we structure our society, causes people to become deranged, then maybe it is reality that must be transformed. In that case, it may be that our forms of social organization are irrational, insofar that they produce derangement. If one person is unemployed, we may question whether the problem is not an individual one. However, if masses of people are unemployed, we can almost be certain that the problem is a socio-economic one. Likewise, if one person is depressed, then that is probably an individual problem. However, if masses of people are depressed, then we can almost certainly point to a social problem.

Madness and Society

If we want to look at the relevance of Hegel to our contemporary society, we can certainly draw some lessons. It’s clear that mental health is becoming an increasingly salient problem. According to the World Health Organization, there has been a 13% rise in mental health conditions and substance use in the last decade alone. 20% of the world’s youth have a mental health condition, depression is a leading cause of disability worldwide, and suicide is the second leading cause of death amongst 15-29 year olds. Yet mental health problems, and those experiencing mental distress, are still socially stigmatized and much taboo still exists around talking about these issues. Moreover, resources and effective treatments to address these problems are still scarce.

In face of the disconcerting increase in depression, suicide, burn-outs, and use of anti-depressants, there are masses of people who cannot keep up the pace, and who are falling behind. This all points towards a collective mania. How long can we keep accelerating our ways of living? How long can we keep working longer, working harder, and sleeping less? How much more time can we dedicate to obtaining a decent wage? In a time where prescription drugs are the go to option, it may be well to remember that mental distress is always a problem in the way we relate to the world. In a world such as ours, mental health is not merely an individual medical problem. Mental health is also a social, and political, problem.