What is this pain all about? Mental illness, philosophy and the search for meaning

My first encounter with mental illness was in books.

I have been a researcher and a teacher in philosophy for about ten years and I encountered the question of normality and psychological abnormality first of all from a purely historical perspective. My doctoral thesis focused in particular on the thought of Michel Foucault, who provided the 20th century with fundamental reflections for critically rethinking the history of psychiatry, psychology, and the human sciences.

Nourished by this theoretical background, I looked at mental illness in a somehow detached way.

But in recent years I have also resumed training as a psychologist, which has led me to compliment my activity as a philosophy teacher with internships in psychiatric hospitals and mental health care centers. This clinical practice has both questioned and stimulated my theoretical thinking: though people coming for help in a moment of psychological distress can be very lucid and critical of psychiatric institutions and their limitations, they still need to find support to give meaning to their suffering.

I thus realized that philosophy and psychiatry still have a long way to go together, meeting precisely on this question of the subjective meaning of illness.

Why does an individual, at a certain point in his life, find her/himself in psychological distress? How can this suffering be objectively defined and measured, but above all, how can it be helped and cured?

To answer these questions, it seems important to me to propose here a journey through the complex history of the relationship between philosophy and mental illness. These relations have often seemed to be a struggle over the definition of “human beings” and “their reason” rather than an objective questioning of different forms of concrete existence.

As I write from a historical perspective, I have deliberately chosen to use, at times, terms that seem anachronistic today, such as “madness” and “madmen”. Luckily, nobody addresses patients as “madmen” anymore in health care settings.

And yet the history of the psychiatric clinic is also the history of “madness”: the history of how philosophers, doctors, and politicians, in Western civilization, have stigmatized, excluded, rejected the mentally ill — the “madmen”.

Something of this stigma probably still remains in the subjective perception of psychological distress, and precisely philosophy, among other disciplines, can help to question and to overcome it towards a more welcoming understanding of the suffering human being.

1. Nobody is normal up close

Image by Gianni Berengo Gardin

“Nobody is normal up close”. Franco Basaglia — the Italian psychiatrist who led the closure of mental asylums in Italy in the 1970s — chose this slogan for the ex-psychiatric hospital he ran in Trieste in the 1980s, based on a song by Brazilian composer Caetano Veloso. The complex relationship between “madness” and philosophy begins precisely in this definition of what normality is for humans as rational beings.

The person we used to call “mad”, even before any medical diagnosis, is an individual who presents abnormal behaviours, who has incoherent speech, and whose perceptions and judgments are impaired.

But how can we define this “abnormality”? It is the “normal” functioning of reason that needs to be understood in order to define its “abnormalities”: mental illnesses.

We should know what “reason” is before defining its absence.

But isn’t it actually the opposite?

What other point of reference should we choose to understand human reason if not mental illness itself, which makes the various rational structures visible through their specific abnormalities (hallucinations, loosening of associations, paranoid ideation, delusions)?

In other words, normality cannot be defined from within. It needs an external anchor.

And that external anchor could be offered — philosophically speaking — by mental illness.

Historically, it was, for example, the study of aphasia (an impairment of language that affects our ability to communicate, following brain damage) in the 19th century that made it possible to understand the neurological basis and functions of language.

Thus, one could say that it is the ‘mad’ man who holds the keys to the truth of ‘normal’ man, since reasonable behaviour is reconstructed from its disappearance into delusion.

As soon as we begin to reflect on mental illness and its history, the very conception of being human, and of human reason and human subjectivity, at risk.

2. Was philosophy afraid of madness?

Can a philosopher be mad?

Philosophically speaking, reason and madness are a matter of statistics: the madman is mainly someone who is different from the others, from the crowd.

The philosopher too is different, being the one who can see the real truth of things, beyond common sense. So the philosopher could also be considered “mad”, since they are going against the norm.

Their discourse will be dissonant and will appear as a delusion.

The philosopher could also be right yet will be mocked and rejected because their truth will not be accepted at that moment.

But things are actually more complicated than this.

Until the 19th century, philosophy was defined in Western civilization as a rational and methodical enquiry of reality as a whole, and of human experience in particular. An irrational, “mad” philosopher was therefore an oxymoron, a contradiction in terms.

It is therefore obvious that mental illness, with its potential of delusions and irrational behaviour, was considered the opposite of philosophical practice.

As Michel Foucault says in his History of madness, modern philosophy operated a “strange coup de force”, formulated in the Cartesian First Meditation.

Descartes (French philosopher, scientist and mathematician, generally regarded as the founder of modern philosophy at the beginning of the 17th century) describes the philosophical enterprise as the search for a primary truth that would resist all possible doubts.

His thoughts on “madness” are worth reading in its complexity as written in the First Meditation:

… although the senses sometimes deceive usabout objects that are very small or distant, that doesn’t apply to my belief that I am here, sitting by the fire, wearing a winter dressing-gown, holding this piece of paper in my hands, and so on. It seems to be quite impossible to doubt beliefs like these, which come from the senses. Another example: how can I doubt that these hands or this wholebody are mine? To doubt such things I would have to liken myself to brain-damaged madmen who are convinced they are kings when really they are paupers, or say they are dressed in purple when they are naked, or that they are pumpkins, or made of glass. Such people are insane, and I would be thought equally mad if I modelled myself on them.

and his own reply to this argument:

What a brilliant piece of reasoning! As if I were not a man who sleeps at night and often has all the same experiences while asleep as madmen do when awake — indeed sometimes even more improbable ones. Often in my dreams I am convinced of just such familiar events — that I am sitting by the fire in my dressing-gown — when infact I am lying undressed in bed!

Philosophical discourse therefore, at least till the 19th century, maintained an ambiguous link with “madness”, a link of rejection but also of fascination.

Sometimes philosophy recognised “madness” for its ability to cross the limits of reason and glimpse truths inaccessible to “normal” people.

There is something “divine” about “madness”, wrote Plato (in Phaedrus), as he likens “mad people” to oracles, lovers, or poets, all capable of brilliant intuitions.

But in madness there was also an inability to see “the true nature of things”, and reason saw in madness its disturbing double.

We can say that philosophy was, until recently, afraid of madness, and, just wanted to silence it.

3. Philosophical and clinical implications from the 19th century onward

The Cartesian negative perception of mental illness began to change radically within the philosophical discourse from the 19th century onwards, when philosophy started to approach the clinical reality of mental illness or the discoveries of psychiatry to find sources of inspiration and reflection.

Phenomenology, existentialism, critical thinking: these are some of the philosophical currents of the 20th century which have entered into an important dialogue with the sciences of the mind, and in particular with psychiatry. And it all started with Nietzsche, who himself suffered from mental illness toward the end of his life.

Phenomenological and existential approaches in psychopathology (Binswanger, Minkowski) have made it possible to re-evaluate and to value the subjective experiences of psychiatric patients, without disqualifying them as mere expressions of chaotic unreason.

Phenomenological psychiatry proposes to return to the meticulous observation of psychological symptoms in their appearance (their “phenomenology”) in order to see them not as a catalogue of objective and pre-defined illnesses but rather projects of existence, unique forms of appraisal of reality.

This is the “existentialist” approach to mental illness: delusions is, above all, a universe of meanings that the patient unfolds from their own existence and whose dynamics can and must be described.

With this new approach, philosophy thus shifts the meaning of “the truth” of the illness, which is no longer an objective and fixed clinical truth. The truth of mental illness lies in what the patients say and live from their reality.

There is a meaning in the pain of mental illness that belongs to the person and that it is imperative to respect.

Furthermore, contemporary philosophy has provided psychiatric medicine with “epistemological instruments”, that is, instruments relevant to the study of the nature, origin, and limits of human knowledge. It has allowed psychiatry to reflect on its own history and the way in which its reflexive paradigms have been constructed, in their scientific as well as political values.

We have already mentioned Michel Foucault, whose reflections on the “history of madness” and on “psychiatric power” have nourished the anti-psychiatry movements since the 1960s, and have helped to affirm new attention for the dignity and freedom of patients with mental disorders.

According to Foucault, psychiatry represents not only the truth of science, but also an institutional power, articulated to deliver public health management and centred around hospitals and clinics.

This is how the dialogue between philosophers and psychiatrists must continue today, and how philosophy and psychiatry can converge. On the one hand, in the need to give form, meaning and voice to the real existences, to the physical experiences of psychiatric patients. On the other hand, in the possibility of building critical movements to question the social and political dimensions of the treatment of mental illness.

4. Body and mind interface and future directions: the call for immunophilosophy?

The challenge for a renewed dialogue between psychiatry and philosophy today is all the more evident as a new paradigm is emerging in the treatment of mental illness, putting the body back at the centre of the theoretical and therapeutic approach. It is an innovative epistemological model, for which behaviours and emotions would find an explanatory principle in peripheral immune mechanisms (“immunopsychiatry”).

To put it very schematically, the novelty claimed by immunopsychiatry concerns both the object and the etiological scope (the search for causes) of psychiatric research. Research on immune mechanisms as possible explanations for a wide range of psychiatric disorders, from autism to depression, from eating disorders to addictions, has multiplied over the last few years.

It is then the body as a whole, or more precisely the “peripheral” body, that is involved in mental illness.

The idea of the immune system being implicated in mental health is something that has been touched upon in previous InSPIre the Mind blogs, you can read some examples here, and here. As I devoted many years of my academic life studying the philosophical meanings of the human body, this seems to me quite an important shift, not only from a medical but also from a philosophical point of view.

Mental illness affects the body in all its expressions, down to the slightest feelings of somatic existence — this body taking shape as a complex and open experience, adapting to the surrounding environment and being transmitted from one generation to the next. Is mental illness therefore a matter for the body and not for the mind? Is its meaning to be determined at the level of a global bodily experience, rather than in neuropsychological dynamics?

With immunopsychiatry, psychiatry puts the body back at the centre of its theoretical and therapeutic approach, inviting philosophy to rethink the body in the context of mental illness. The immunopsychiatric paradigm allows then a new reflection on the subject (healthy and sick — normal and “abnormal”), escaping the body/mind dualism that has caused so many words being produced by the pen of philosophers.

If mental illness emerges from the dispersed and tortuous networks of somatic immune responses, psychicological subjectivity itself is structured from the plural dynamics of bodily experience, both on a spatial dimension (other bodies, individual or social) and a temporal dimension (generations of bodies communicating through genetic filiations and the experience of pregnancy).

The very identity of the subject is questioned, being shaped in complex and heterogeneous bodily experiences. Research on mental illness and the body thus makes it possible to reopen the question of the self, in its development and definition.

But it also makes it possible to take up again and reconstruct, in a coherent discourse, the intricate paths that have led this specific individual, in his or her own history, to psychic distress. And these themes of identity, subjectivity, history and existential meaning, are all obviously familiar to philosophy.

Immunopsychiatry calls for the formation of a new philosophy (an immunophilosophy?), which again takes up an essential question: what is the meaning of “mental illness”, or better, what meaning can patients and therapists give together to psychicological suffering?

What is this pain all about?