Awais Aftab, MD

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Robert Chapman, PhD (they/them or he/him) is a philosopher in the United Kingdom (UK). They are an associate of the department of philosophy at the University of Bristol, UK, focusing on the philosophy of neurodiversity. They have published widely on issues in philosophy of disability, the ethics of autism, and critical neurodiversity studies, and are currently writing their first book on the philosophy of neurodiversity. Their Shirley Foundation-funded doctoral research was carried out at the University of Essex between 2013 and 2018 and focused on the ethics of autism. They have taught at the University of Essex, King’s College London and the University of Bristol. They are proudly neurodivergent and disabled. They also blog for 

Dr Chapman’s work on the intersection of neurodiversity and psychiatry has had a substantial impact on my own thinking, and their writings have consistently forced me, and many others, to rethink long-standing assumptions related to pathology and medical care. Among Dr Chapman’s writings, of particular note are: “Neurodiversity Theory and its Discontents: Autism, Schizophrenia, and the Social Model of Disability,”

 “The Reality of Autism: On the Metaphysics of Disorder and Diversity,”

 and “Neurodiversity and the Social Ecology of Mental Functions.”

 In recent years, the neurodiversity perspective has not only emerged as a vital player in our philosophical understanding of health and disease, but also has also had begun to shape how societies relate to disabled individuals. Furthermore, the neurodiversity perspective and sister movements such as Mad Pride center the voices of mad and neurodivergent individuals, transforming what has so far been, in the words of Michel Foucault, PhD, “a monologue of reason about madness,” to a dialogue enabling collective self-reflection on the relational nature of dysfunction and disability.

: Let’s start by an introduction to the neurodiversity movement and the neurodiversity paradigm. What is neurodiversity and where does it clash with mainstream medical thinking?

: The neurodiversity movement is a social justice movement pushing for a shift away from the default pathologizing of mental, developmental, and cognitive disability, and towards what I have called a 

 approach to understanding disablement. It all started when autistic individuals began meeting and raising consciousness online in the 1990s. Many realized they were tired of being represented as tragic deviations from supposedly normal functioning, and they were also often traumatized by ensuing attempts to treat or cure their autism. Eventually, as a new way to challenge how we think about normality, they began to talk about whether the principle that increased biodiversity is necessary for a robust ecosystem also applied to neuro-cognitive diversity within species. Just as we value, see beauty in, and try to conserve biodiversity, why not think about neuro-cognitive diversity in the same way? Based on this, Judy Singer, a member of these communities and, at the time, a sociology student, coined the term 

 and called for a “politics of neurological diversity” in her 1998 thesis. Singer circulated her thesis, which was grounded in the theories of disability studies, among other autistic activists before publishing a revised version as a book chapter in 1999.

 This became a founding text of the movement, which rallied around both Singer’s concept as well as existing themes from disability studies.

 was proposed a bit later, in 2012, by autistic scholar Nick Walker, PhD (she/her),

 who was also a graduate student at the time. By then the ideas initially developed by Singer were increasingly being adopted by individuals with other diagnoses such as bipolar, dyspraxia, and attention-deficit/hyperactivity disorder (ADHD). Walker was interested in the philosophical implications of this broader application and how it challenged theoretical assumptions and cultural and scientific practices. Walker proposed a distinction between the 

, which she took to be dominant and to rest on a relatively restricted conception of neurological, cognitive, and developmental normality, and the emerging 

, which begins from the acknowledgement that neurological diversity is natural and beneficial for the cognitive and cultural richness of the species. On this paradigm, instead of being labelled medically 

, those who are more enabled in a given society are considered more 

, while those who diverge further from functional norms are more 

. Walker argued that developing and cultivating such a paradigm shift, to then be adopted for research, policy, and practice, would be necessary for the long-term emancipation and well-being of neurodivergent individuals. Although Walker's chapter was relatively brief, it became highly influential within the movement, and I count it as another of the seminal texts of neurodiversity theory.

: You have talked about neurodiversity as a sociopolitical idea, centered around social models of disability, as well as neurodiversity as a scientific concept, offering a new way of thinking about function and dysfunction. Can you elaborate on these strands of neurodiversity (among other strands) and the shape they have taken in your own work?

: I see the cultural paradigm shift as quite similar to the change we have been seeing regarding the LGBT community, away from pathologization and towards pride, acceptance, and inclusion. The neurodiversity movement is also part of the broader disability rights and justice movement. With neurodiversity, while there is a long way to go, we are already seeing, for instance, neurodiversity paradigm vocabularies being used in newspapers and magazines, and a shift to disability rights-based practices for neurodivergent individuals in schools and workplaces.

Among other things, researchers increasingly recognize neurodivergent strengths alongside limitations.

Accompanying this, a scientific paradigm has also been emerging, albeit in a somewhat piecemeal way. More neurodivergent individuals have become involved in research, and more neurotypical researchers have begun to listen to neurodivergent perspectives. This is beginning to change how researchers formulate hypotheses and produce knowledge. Among other things, researchers increasingly recognize neurodivergent strengths alongside limitations, study cognitive problems as relational rather than as arising from individual deficits, and view neurodivergent disablement and distress based on a social model of disability rather than a medical model.

In my own work, I developed the ecological model of functioning to help clarify and formalize the theoretical basis of the emerging shift in the scientific paradigm, and to challenge the default pathologization of neurodivergence. I became interested in developing a new model of mental functioning partly because neurodiversity proponents had long been (successfully) using the social model of disability, and yet many researchers were still dismissing the idea that things like autism were not pathological. I realized that this was, at least in part, because the social model of disability leaves the dominant notion of individual dysfunction or impairment relatively intact, which is important because individual dysfunction is a core part of the definition of mental disorder (or of somatic disorder for that matter). As such, even the most successful application of the social model, while vital in other ways, is insufficient for undermining the ascription of neurological or mental illness, disorder, or pathology. After all, we can and do use social model interventions for things everyone agrees are genuine pathologies, such as dementia. Thus, I realized we needed an alternative model of functioning to augment alternative models of disablement and to help shift the paradigm.

Traditionally mental functions and dysfunctions have been determined through what I call “individualist comparativist” models, which compare all individuals to an aggregated norm and then rank them in levels of functioning. These models—which I date back to Darwin’s half-cousin, the eugenicist Francis Galton—seek to be continuous with the kind of evolutionary biology that focuses on individual fitness or adaption, and they thus rank fitness levels from highest to lowest in members of a population. If we accept these models, then it seems like an objective fact that members of low-ranked groups such as autistics and dyspraxics are naturally dysfunctional, and hence pathological, in comparison to neurotypicals—even if the social model can be helpful for alleviating disablement. The continued use of these models reifies neurodivergent disablement as natural fact and also lends scientific authority to the normalization of neurodivergence.

By contrast, the ecological model, as the name indicates, is more influenced by how ecologists talk about functioning. Ecologists tend to be less interested in ranking individual fitness levels, and more interested in how broader systems function as a whole, how functions emerge from the relations between organisms, and how the dominance of some forms of organisms can be harmful for the functioning of others. Bearing this in mind, in 

 I drew on theoretical and empirical research to argue that many neurodivergent functions, or relational functions that emerge from group neurodiversity, are overlooked on the traditional models.

 To avoid these problems, I then combined the arguments of neurodiversity proponents with ecological functional models to propose a preliminary ecological model in line with Walker’s call for a paradigm shift. To the extent this proves to be useful for researchers, I hope it will help with the scientific paradigm shift by orientating researchers towards asking different questions, formulating different hypotheses, and ultimately producing knowledge that helps us move beyond the default pathologizing of neurodivergent disability, and which supports a broadly conservationist approach to neurodiversity.

: How does your ecological model of mental functions play out within psychiatry and in the context of existing philosophical debates about neuropsychiatric dysfunction?

: It may be helpful to look at this historically. The modern debate could be dated to the 1960s, when the antipsychiatrist Thomas Szasz, MD, argued that mental illness was a myth and that psychiatry was a pseudoscience. Szasz was happy to acknowledge that neurological illnesses exist. But he nonetheless held that there could be no mental illnesses, since for him, an illness must be biological (including neurological) by definition. The Szaszian position, while challenging the pathologization of emotional distress, is entirely continuous with the Galtonian project of ranking neurocognitive functions in relation to an assumed norm. This challenged the psychoanalytic psychiatry of the time, which was not based on biological research, and pushed psychiatry towards the more biocentric and cognitivist models that are still used today. While this argument still has some influence, contemporary psychiatry has largely neutralized Szasz’s critique not just by analyzing the conceptual flaws of his arguments, but also by finding ample evidence that biological processes in some form or another, though they may not take the form of discrete dysfunctions, are part of the story for many conditions listed as mental disorders. In many ways contemporary psychiatry has thus become more Szaszian, although nobody likes to admit that.

By contrast, while they have some surface overlap with Szasz in that they challenge pathologization, the neurodiversity perspective and my ecological model present a novel philosophical position that is equally at odds with mainstream psychiatry and the Szaszian tradition (including its various offshoots within critical psychiatry). At base, the ecological model rejects the assumption that humans have enough neurocognitive uniformity across the species that legitimizes the notions of normal neurological functioning. Instead, my model begins with the acknowledgement that we are a neurologically diverse species, and the insight that neurocognitive functions and dysfunctions are (at least in significant part) relationally produced and upheld, both between different minds, and between mind and environment. It is not just that cognitive niche construction enables or disables different forms of functioning, it is also that a trait associated with individual disability may contribute to functioning at the group level, while a trait associated with individual ability may contribute to maladaptive group functioning. So things are a lot more complex than being normal or abnormal.

Part of the significance of adopting this model is that we recognize more neurodivergent mental functions, and that many dysfunctions are relational, often stemming in part from the neurotypical side, rather than being intrinsic to neurodivergent individuals. Simultaneously, by incorporating a social model analysis of cognitive niche construction, this also allows us to shift to viewing neurodivergent abilities as forms of marginalized functioning rather than inherent dysfunction. This model challenges the idea that many neurodivergent individuals necessarily have neurological or cognitive pathologies, as well as the idea that neurotypicals are necessarily superior, while fully acknowledging the fact of neurodivergent disablement. Moreover, unlike the Szaszian critique of psychiatric pathologization, this model is compatible with disability justice more broadly, because it applies equally to learning and cognitive disabilities and neurodevelopmental disabilities, instead of reinforcing their pathologization. More concretely, I thus hope the model will help reorientate the surrounding biopolitics, away from the normalizing tendencies developed by 19th-century eugenicists, and towards a conservationist approach to studying and supporting human neurodiversity.

: A common objection that is raised against neurodiversity is that the framework applies poorly to severely disabled individuals who have high support needs, and may live in specialized settings. Given that this may be on the minds of many readers as well, I think it is worth bringing up here.

: This is a very important question on a complex topic. I will restrict myself to a pair of key points. First, the form of neurodiversity that I, and I believe most proponents, endorse does not deny that there are different forms of disability, and that in some cases much more direct support is needed (even if we have critiqued the utility of terms like 

). In fact, the clear implication of adopting social models of disability (not to mention my ecological model of functioning) would be that individuals with more complex disabilities should get more support, not less.

A key point of contention, of course, regards whether we prefer to see complex disabilities more as mental pathologies to be treated, or marginalized minorities to be supported. This brings me to my second point. Because my approach to neurodiversity is based on a disability justice perspective, it relies more on standpoint epistemology, centering the lived experience of marginalized individuals or groups. My own view, then, is that we need to do more to center the voices of those with intersecting disabilities and high support needs when talking about those who sit at the same intersections (as I wrote about 

 At the moment, we have no data on the views of those considered severe on such topics. Interestingly, though, just looking through texts written by nonverbal autistics with intersecting disabilities and high support needs, it is quite easy to find many who hold views consistent with the neurodiversity perspective, as I have 

 Indeed, some of the most influential neurodiversity proponents, notably the late Mel Baggs, were labelled severe and had high support needs. So, we cannot assume that everyone with higher support needs would reject the neurodiversity perspective. My hope is that empirical researchers will, where possible, survey the preferences of those with high support needs in a more systematic way. As a philosopher I do not have the right resources to do that kind of research, but I can say I do think that should be the starting point of any conversation on this.

: A related issue is that of whether the neurodiversity movement rejects medical care per se. My understanding is that the proponents of neurodiversity movements are not against the use of medical interventions, but these medical interventions need to be offered on terms that are acceptable to and desired by neurodivergent individuals. Is that an accurate characterization? What do you think medical care would look like within a neurodiversity paradigm?

: Views differ among neurodiversity proponents, but for the most part, I think you are right. The key thing most are against is the default assumption that neurodivergent individuals should be normalized, and, in turn, most are against the invariably harmful attempts to cure us or to prevent neurodivergence from existing. What we want is support so neurodivergent individuals of all abilities can thrive. In certain respects, medical care would not change all that much. For instance, when it comes to depression, the neurodiversity paradigm, although it is certainly not committed to these, may be compatible with a range of existing approaches found in many forms of psychotherapy. And, for that matter, it is equally consistent with alternative approaches from beyond the Western medical tradition.

But there are certain things most neurodiversity proponents are very against. An example of this is Applied Behavior Analysis (ABA), which was initially used as gay conversion therapy and is still used on autistics. Traditional ABA uses a system of punishments and rewards to alter behaviors, although more recently punishments have become less popular. Today it is often touted as the gold standard of autism interventions, despite the protests of many autistic individuals who are clear that their experience of ABA was dehumanizing, focused on normalization, and traumatized them. Myself and my co-author Virginia Bovell recently reviewed the evidence and ethical arguments for or against ABA for a forthcoming book chapter. We found the evidence stacked up against the moral permissibility of ABA. I have uploaded a 

 and I invite anyone who is skeptical of worries regarding ABA and normalization to read through and assess the reasoning and evidence we present.

While I advocate moving towards a neurodiversity paradigm, I do not simply dismiss those autistic individuals who see themselves as ill and who wish to be cured. To help make sense of this from a neurodiversity paradigm perspective, I—somewhat tentatively—

 which refers to when the inner identity or goals of an individual clash with their neurotype to the extent that this becomes distressing. In such a case, I leave it open whether the individual wishes to focus more on changing their self-image (eg, through talking therapy) or their neurotype (eg, through biomedical intervention). Of course, at this point, there is no biomedical intervention for autism, and it looks to me like the whole project of trying to treat or cure autism itself has catastrophically failed. So, with autism, I would imagine that focusing on one’s identity rather than one’s neurotype would be better in practice, even for those autistic individuals who hold out hope for a neurotype change. But in other cases, neurodivergent individuals do use biomedical intervention, as can be seen with ADHD or bipolar disorder. While I agree with many critiques of the pharmaceutical industry, I fiercely support those who find medication helpful, and am strongly against the kind of med-shaming that occurs among some critics of psychiatry. In the long run, though, I would hope that, if the neurodiversity paradigm were widely implemented, then the need and desire for medication would lessen, since educational, occupational, and social expectations and environments would also change accordingly.

: Neurotype dysphoria reminds me of the now obsolete category of ego-dystonic homosexuality and the on-going debates around gender dysphoria. At some point it was considered okay, but it is no longer considered ethically acceptable for a medical professional or psychologist to engage in interventions with the attempted aim of converting the homosexual orientation of an individual distressed by it to heterosexual orientation. Do you think the case of autism is significantly different in certain respects that neurotype dysphoria will not run into the same ethical issues as ego-dystonic homosexuality?

: Just to be clear: I am firmly against attempts to develop a cure for autism. I do not think it is morally permissible to spend limited research funds on something most autistic individuals, including myself, see as a form of eugenics. The neurotype dysphoria concept was more meant to acknowledge the very real suffering of those who do wish for a cure. Right now, we live in a world where some neurodivergent individuals consider themselves ill and do not feel that the neurodiversity paradigm has the conceptual space to acknowledge this. I wanted to find a way to acknowledge this kind of experience while also refraining from pathologizing the neurotype itself.

Another reason I suggested it was that I suspect a lot of individuals experience milder manifestations of neurotype dysphoria (I certainly have, although not to the point of ever wanting a profound change). I imagine even some neurotypicals experience neurotype dysphoria. So I hope that this concept will be helpful for a variety of individuals, including for some pro-cure autistics, but it should not be seen as legitimizing the search for a cure. And to be clear, I do not think the term will work for everyone or cover every issue. It will likely only be temporarily useful, as is the case with all such concepts. If social conditions change, the notion will become obsolete, perhaps even unacceptable. If that happens, I will welcome that as a sign of social progress.

: When it comes to how we conceptualize autism within the context of neurodiversity, I am often unclear on where autism ends and other mental health problems begin. For example, parents of autistic children often seek help for a variety of problematic behaviors, such as repetitive banging or hitting of head; biting of hands and fingers; extreme sensitivity to commonplace sights, sounds, or smell; or inability to tolerate even minor changes in daily routine. When you think of autism, where do you position these behaviors within the fuzzy construct? Do you see them as distinct from, or peripheral to, the core autistic self?

: The first thing to say is that I advocate moving away from notions such as the 

 altogether, if by that we mean something that all autistic individuals share, and which is distinctive of autism. That would contradict all the historical, biological, psychological, and sociological research on autism, which, as I have argued in a number of places, shows it to be a shifting, culturally bound construct that maps on to different rough clusters of neurocognitive dispositions at different times. Saying that, I do not think that the kind of things you describe are core parts of anyone’s authentic self. They are things anyone might experience or do in certain harmful environments. Autistic individuals are subjected to such environments more than most, and therefore tend to do these kinds of things more. Of course, that this is so will also reflect the various neurocognitive tendencies associated with autism to some extent, but for the most part it seems more helpful to focus on the environment.

: You have been quite critical of some strong social constructionist positions which argue for the rejection of all psychiatric categories, including categories such as autism, on the basis that they lack a neurobiological essence and are therefore invalid medical constructs. You have argued that such denial of autism as a category erases autistic culture and deprives them on their disabled identity. Can you elaborate on this?

: Well, I am a constructivist myself, and I have often critiqued biocentric and essentialist depictions of mental disabilities. But yes, I am equally against a specific kind of constructivism that stems from the Szaszian antipsychiatry tradition, which argues that both the concept of mental disorder, and specific classifications, are just myths. My issue here is part theoretical, and about how this position is not really convincing once critically assessed. I covered this in detail in my article “

 which provided a clear rebuttal of recent Szaszian and critical characterizations of autism as a myth, and clarified how autism is both constructed and part of material reality. But my worry is also in part political, which I did not explain in the article and is worth clarifying here.

I do not believe that Szasz’s ontology, even in its updated form, is compatible with service-user liberation in the long run.

To cut to the core issue, I find Szasz’s position abhorrent since, based on his hard-right political views, he developed his theoretical critique of psychiatry to establish that individuals who claim to have mental illnesses are essentially all just impersonating or role-playing, pretending to be ill to avoid responsibility, which may arguably be considered as malingering, despite Szasz’s caveat that the mentally ill individual may be lying “both to himself and others.”

 This boils down to the fact that Szasz thought service users were essentially all liars and that this needed to be exposed. Until recently, many on the left, such as Peter Sedgwick, thus critiqued Szasz, and in reply Szasz was openly disdainful of progressives, and happy to gloat about how his theorizing was grounded in a neoliberal, Hayekian politics. In the past decade or so, though, many Szaszian medical professionals have combined the Szaszian analysis with social justice rhetoric to reframe the Szaszian ontology as somehow progressive, even as a critique of neoliberalism. To do this, they essentially keep the Szaszian ontology (biological essentialism about health) and theory (that mental illness is therefore a myth, and diagnoses are lies), but reverse the historical narrative, suggesting that the psychiatrists were the first to suggest these fictional diagnoses, and that service users have since been tricked into believing them.

While I have every sympathy with other service users who, like me, are angry with psychiatry and the misleading claims many clinicians and researchers have often made, I do not believe that Szasz’s ontology, even in its updated form, is compatible with service-user liberation in the long run. It undermines and gaslights those service users who do find a medicalized approach helpful and who seek diagnosis and recovery (eg, from eating disorders). It is also harmful when we consider that many of us have reclaimed psychiatric terms such as autistic to form minority cultures and join with the broader disability rights movement to resist the medicalized approach. Instead of supporting our self-emancipation and recognizing the nuanced positions we have on the metaphysics of diagnosis, professionals and critics working within a Szaszian ontology (where they identify as Szaszian or not) still routinely reduce us to gullible victims, since there is not really any space for a more nuanced analysis within their framework. To me, such contemporary critical positions mainly function to erase our agency, identities, voices, and cultures, and to undermine our efforts to resist the medicalized approach.

: Something you have articulated quite well is the idea that pathologizing first happens in society and that psychiatrists just officially medicalize ways of being that have already by pathologized by the society in some way. You write, “psychiatrists can, for the most part, only medicalize differences that have already implicitly been deemed pathological by the society they live in. For instance, psychiatrists only classified homosexuality as a mental disorder—and, importantly, only could have done so—because society was already deeply homophobic, and had already decided that being gay was a fundamentally bad, sick, thing. Today, if UK psychiatrists tried to re-medicalise being gay, they simply would not be able to because society would be so outraged... It is society that mainly decides who is pathological or not, not psychiatry...”

 How do you think this insight should inform individuals, both within and outside psychiatry, who are concerned about over-medicalization and wish to counter it?

: Okay so this again relates back to the contemporary Szaszian reduction of neurodivergent individuals to victims of psychiatric lies. More specifically, I wrote this in response to the oft-repeated Szaszian claim that psychiatry, and in particular the DSM taskforce, is a uniquely powerful force that is medicalizing normality. I call this “the DSM conspiracy narrative,” since it presents the fact that taskforce members vote on diagnostic classifications as some kind of shocking truth about psychiatry, which is taken to show it to be some kind of elite conspiracy with the power to decide who is normal or not. To be clear, I agree that we do often wrongfully pathologize normal variations, and I also think there are a number of hugely significant problems with the DSM (I am currently writing a book that locates that basis of the DSM conception of mental disorder in 19th-century eugenic theory and which argues that it is still bound up with this way of thinking). But despite being among the harshest critics of the DSM and all it represents, I also think this particular narrative is deeply problematic and that ultimately it reinforces disempowering ableist narratives that undermine our individual and collective agency.

There are a number of interrelated issues here. First consider that, at least in the UK where I live, it is unthinkable that psychiatrists could pathologize homosexuality today. Once we accept this, it becomes apparent that, not just what psychiatrists do medicalize but what they could medicalize, is in large part already set by social forces outside their control. I emphasized this because I think any realistic attempt to resist wrongful pathologization must take this as the starting point of its analysis rather than by framing psychiatry, or the DSM taskforce, as some kind of elite conspiracy that has the power to decide who is normal or not. If anything, for the most part DSM taskforce votes on diagnoses are channeling the already settled outcomes of wider public debates that have already taken place in the years leading up to each DSM revision. Second, it is also important to note here that researchers voting on classifications is consistent with how classifications are decided in the rest of medicine, not to mention in science more generally. While this conspiracy narrative has clearly been good for Szaszian clinical professionals to generate tabloid headlines or book sales, it is at base a distraction that will not be helpful for emancipating those who are mentally disabled or distressed in the long run.

Importantly, my distaste for the DSM conspiracy narrative also relates back to my worries about the erasure of neurodivergent agency. A big part of why challenging this narrative is important is that over many decades, countless neurodivergent individuals have been part of debates regarding how we are categorized. Many have campaigned for the inclusion or expansion of DSM classifications, just as many have campaigned for the removal or contraction of others. As just one example, it is worth reading Kapp and Ne’eman’s 

 on how autistic advocates were part of the construction of autism in the DSM-5. This is important to note because it means our neurodivergent agency is part of diagnostic looping effects that determine each DSM edition, just like the agency of other actors, such as pharmaceutical corporations or DSM taskforce members. Given this, any given DSM vote on diagnostic classifications should be seen—albeit to varying extents in each case—as the outcomes of decades’ long co-construction rather than something solely determined by medical professionals and corporate interests. While I am all for critiquing and eventually abolishing the DSM or specific diagnoses, I would urge critics, whether within or outside psychiatry, to recognize that analyses which overlook the fact that the DSM is co-constructed with significant input from individuals with mental illnesses or neurodivergent individuals are not just misleading, they also actively erase our agency and histories, and contribute to ableist tropes about us being powerless and passive victims.

: There are increasing efforts to apply the neurodiversity paradigm to conditions such as ADHD, dyslexia, and even conditions such as schizophrenia and personality disorders. I wonder what the boundaries of the neurodiversity paradigm are, what falls within its scope and what does not. It seems to me to be an open question. This is also presumably not a binary issue, that is, there are likely situations where the neurodiversity paradigm may apply, but only partly so (which I suspect will be the case for many psychiatric conditions). There are clearly some limits to the neurodiversity paradigm, so as the neurodiversity paradigm is increasingly studied and increasingly applied, what are your thoughts on how the over-application of neurodiversity may be avoided by activists and scholars of today and tomorrow?

: This is an important question I have grappled with a lot. Personally, I think it is better to ask 

 we can include an individual or group within the paradigm rather than 

 we can. Based on this, I have argued (eg, 

) that there should be room for a non-Galtonian conception of pathology within the neurodiversity paradigm, so we can include those who prefer to see themselves as ill without pathologizing those who do not.

But I think you are really asking about which standard we should use to determine what counts as pathology once we reject the Galtonian approach. Neurodiversity proponents do not yet have a clear way of distinguishing genuine pathology from marginalized functioning. Some critics see this as a weakness of the neurodiversity paradigm, and they suggest that the neurodiversity paradigm leads to some kind of naïve, antiscientific relativism. But I think that is far too hasty. Exactly where health ends and pathology begins has always been a problem and always will be. And really it is a philosophical and pragmatic issue rather than a scientific one. While this is a problem for neurodiversity proponents, it is equally a problem for everyone else, including for critics of neurodiversity. Those who dismiss the neurodiversity paradigm for encountering a problem that is equally shared by everyone else overlook this.

Personally, I advocate what I hope will be a more inclusive and liberatory approach, again by incorporating standpoint epistemology alongside social and ecological models of disability and functioning. Instead of trying to come up with more and more refined ways of objectively demarcating health from illness, I think it is probably better to move towards incorporating the perspectives of those classified into whether they should be counted as pathological or not. If patients diagnosed with schizophrenia (or whatever other name they chose) came to find the depathologization useful, then I would fully endorse including them in that kind of analysis. By the same token, if they mainly found this way of looking at it unhelpful and, on reflection, preferred to see themselves as mentally ill, then I would begin with that as the starting point of any future analysis. In general, I think that whether a disability is depathologized has to be the product of consciousness raising from within to be emancipatory. If it was enforced from the outside then it may end up being epistemically oppressive. The approach I advocate thus avoids simplistic claims to objectivity and is more about opening up conceptual and existential space for those who are marginalized and for groups to collectively reimagine what their disablement means to them.

Just to be clear, this is a pragmatist approach rather than an anything goes kind of relativism. (Here I agree with Robert Spitzer, MD, architect of the DSM-III, who 

 that whether we call schizophrenia a disorder should ultimately be a pragmatic consideration.) I see individual and group preference as a key factor in whether we should focus more on, say, medical intervention or societal acceptance, for any given trait or disability. But sometimes different factors might conflict. If someone tried to use neurodiversity paradigm vocabulary to justify support for, say, harmful, unethical behavior, then that would be a clear co-option and abuse of the framework. In general, the kinds of things I am happy to endorse depathologizing—voice hearing, autistic stimming, hyperactivity, and so forth—are not intrinsically harmful.

: What hopes do you have for the future of neurodiversity theory and practice?

: I am excited about how neurodiversity theory and neurodiversity studies have been coming on in leaps and bounds over the past few years especially. We have talked about the need for a new paradigm in the 

 sciences for decades but a shift has not happened, mainly because nobody has come up with a workable alternative (and yes I am aware of the existing attempts). I believe that neurodiversity proponents have actually been getting on and building the basis for a different paradigm, even though it is still very much a work in progress. This has been led by grass roots advocates and has been strengthened more recently due to a concentrated effort of neurodivergent individuals to train in a variety of fields to further develop the paradigm.

But there is still a lot of work to do and there are a lot of problems and barriers we are facing. One thing I often worry about is how the vocabularies of neurodiversity are being co-opted by already established neurotypical clinicians, researchers, corporations, and so forth in ways that function to uphold rather than challenge the status quo. Many of the leading pathology paradigm theorists of autism have now rebranded themselves as neurodiversity advocates without giving up on their harmful, pathology paradigm theories and commitments. My hope is that the more radical, liberating aspects of the movement will prevail.

This brings me to a second point, which regards my hopes for institutional support. I hope educational and research institutions will make meaningful moves to support neurodiversity research by neurodivergent researchers. There are many disabling barriers in academia that are stifling for neurodivergent students and researchers and may have multiple marginalizing characteristics. Moreover, while an increasing number of neurodivergent individuals have now trained as scholars and are producing important neurodiversity paradigm research, there are few stable jobs for us in universities given that our approach often defies traditional boundaries and expectations. This is despite the interest many students have in learning about neurodiversity theory and the impact neurodiversity paradigm research and advocacy is having. By the end of the decade, I hope to see universities establish neurodiversity research centers, neurodiversity studies degrees, and neurodiversity studies lectureships. I would also like to see neurodiversity theory modules increasingly included in clinical training, not to mention in humanities and social science degrees.

Finally, within the neurodiversity movement, there are still remnants of the pathology paradigm that I think need to be overcome. For instance, some neurodiversity proponents still see neurotypes as natural kinds with timeless biological essences. I hope we can overcome this kind of biological essentialism since it is theoretically untenable and in my view contributes to a lot of needlessly toxic discourse. Relatedly, we also need to have more of a widespread acknowledgement that neurotype is, to some extent, fluid, and that even neurotypicals become neurodivergent if they live long enough. Working towards a more fluid and inclusive understanding of neurological identification will, I hope, not just be more liberating for neurodivergent individuals, but also help establish how the neurodiversity paradigm will be better for everyone. After all, even neurotypicals cannot live up to the ideal of normalcy. They have closer proximity to the ideal, sure. But since nobody is wholly normal, adherence to the ideal is, I think, harmful in other ways even for those who are temporarily enabled by it.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the

Dr Aftab and Dr Chapman has no relevant financial disclosures or conflicts of interest.

1. Chapman R. Neurodiversity theory and its discontents: autism, schizophrenia, and the social model of disability. In: Tekin S and Bluhm R, eds. 

The Bloomsbury Companion to Philosophy of Psychiatry

2. Chapman R. The reality of autism: on the metaphysics of disorder and diversity. 

3. Chapman R. Neurodiversity and the social ecology of mental functions. 

4. Singer J. ‘Why can’t you be normal for once in your life?’ From a ‘problem with no name’ to the emergence of a new category of difference. In: Corker M and French S, eds. 

5. Walker N. Throw away the master’s tools: liberating ourselves from the pathology paradigm. In: Bascombe J, ed. 

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Multiply-disabled autism and intersectional feminism

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Are the voices of the “severely” autistic being silenced?

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Health and Wellbeing for a Neurodiverse Age

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The Myth of Mental Illness: Foundations of a Theory of Personal Conduct

Will opposing psychiatric labels stop over-medicalisation?

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12. Kapp SK, Ne’eman A. Lobbying autism’s diagnostic revision in the DSM-5. In: Kapp S, ed. 

Autistic Community and the Neurodiversity Movement: Stories From the Frontline

13. Spitzer RL. The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. 

Articles

Is neurodivergence to be cured or is it a healthy part of our social ecology?

The Neurodiversity Paradigm in Psychiatry: Robert Chapman, PhD

Wouter Kusters, PhD, is a Dutch linguist and philosopher. He is the author of 

; Lemniscaat, 2014). An English translation of 

 was published in 2020 by MIT press with the title 

A Philosophy of Madness: The Experience of Psychotic Thinking

 (translated by Nancy Forest-Flier). Dr Kusters works as an independent researcher, writer, teacher, and consultant in Gouda, Netherlands. For details, see his website 

 was based on Dr Kusters’s own experience of a psychotic episode in 1987. It won a pair of prizes in the Netherlands: the Van Helsdingen Award (2004) for the best work on the intersection of philosophy and psychiatry, and the Socrates Award (2005) for the best and most inspiring Dutch philosophy book of the year. After the publication of this book, Dr Kusters made a career switch from academic linguistics to a career as an independent writer and researcher, and started studying again as an undergraduate philosophy student, during which time he published his second book on psychosis 

 (Lemniscaat, 2007). Shortly afterwards, in the summer of 2007, he experienced his second episode of psychosis, which led to a psychiatric hospitalization, and provided further impetus for him to continue his work on philosophy and madness. He finished his Masters’ thesis in philosophy in 2010, which formed the basis of an updated version of 

. His books were a success in Netherlands and were met with widespread acclaim. The publication of the English translation of 

 has brought his work to the attention of the English-speaking world, and it has prompted a renewed debate on philosophical and phenomenological perspectives on psychosis as well as the relationship between philosophy and psychosis.

: I imagine you may be getting tired of introducing your book again and again! Perhaps we can spare you some of that repetition by linking to sources where such introductions are available, but I think it would be prudent for us to begin with at least a few words regarding the nature of inquiry you are undertaking in 

, and how that relates to your own experiences of psychosis.

: My book is a philosophical treatise in the tradition of Montaigne’s 

; in the vein of Nietzsche’s and Kierkegaard’s approaches to thought, writing, and life; and with affinities to the early works of the French existentialists, Sartre and Camus. What brings these works together is the focus on philosophical problems of good and evil, life and death, I and the other, without getting lost in arid, abstract, academic reasoning for the sake of reasoning itself. On every page the driving question with these authors is: “what does all this thinking, reflection, and all these ideas, actually mean for my life as a writer, and for the life of the reader?” My book does not have the form of problem-solving argumentation, let alone that of a psychopathological theory, with a set of propositions about a clearly delineated empirical phenomenon. It could be categorized as 

, with inclusion of the darker aspects of spiritual travelling. It has also been called auto-ethnography: a description of personal experiences and reflections, undertaken in order to examine the wider ethos against which the experience takes place. The particular ethos that is at stake in my book would be the ethos, the mores, the habits, and discursive practices that are called philosophy in relation to madness.

My book does not present a psychopathological theory, but it does focus on madness as a lived experience, as a concept in philosophy, and as a phenomenon called psychosis in psychiatric practice and theory. By stressing the experiential character of psychosis, which I have access to via my own memory, as well as via all kinds of reports and first-person narratives, the direction of my exploration is towards comparable experiences and their expressions. This brings us to all kinds of philosophical thoughts, bordering on reflections around religion, mysticism, and spirituality, but also to important themes of language, fiction, and nonfiction. For any psychiatrist educated a little beyond the mainstream medical illness, cure, and therapy narratives, it must be clear that my exercise brought me into the small but highly professional and well-informed tradition of phenomenological psychiatry.

For a further overview of what my book is all about, I recommend the short interview in the 

: You have argued that a philosophical investigation of psychosis provides a better and less prejudicial approach than many mainstream psychological and psychiatric accounts. What sort of prejudices do you have in mind?

: The main prejudice concerns the usual way of approaching psychosis as a negative or a lack and leaving it there. That is, seeing it purely as a deficit, a disorder, a nonfunctioning of some aspect of the mind/brain/body that is supposed to be well-functioning in the nonpsychotic individual. Take for example the idea, found in various kinds of mainstream accounts, that psychosis is some kind of 

. Such a judgement implies that there is good, proper thought, and that psychotic thought can be sufficiently defined as a disturbance, a disordering of this normal, natural way of thinking. It may be said that the disorder is one of jumping too fast to conclusions, or a dysregulation of perceiving salience properly, or an inability to synthesize information coherently, or it is just being plainly illogical. All such approaches share the assumption (the prejudice) that psychosis can be sufficiently defined by what it is not.

The implication of such accounts is that the psychosis is just a disruption that should be suppressed and taken away in order to let the normal flow of experience run again uninterruptedly. It is assumed that there is a healthy, sane part, and an insane, psychotic part, both manifesting themselves in various contexts and intensities. Therapy then consists in identifying and annulling the psychotic part (eg, by medication, by CBT, or by so-called ‘psychoeducation,’ and stimulating the healthy part). The patient then eventually learns to associate him- or herself with the healthy part, dissociate from the disordered part, and to consider the psychosis as the illness, not belonging to who he or she really is, but as something that was intruding from the outside. They learn to say: “the psychosis disturbed the real me.” Instead of: “the psychosis showed a different aspect of me.” It thereby dissociates them from their own experiences, memories, and past.

So, the assumption in much theory, and the accompanying practices, is that the life-world of the individual is affected by a natural disorder, which eventually impairs the individual in his or her freedom, in his or her meaningful interaction with others, and in his or her sense of being a conscious individual. What most of these accounts simply miss is that the psychotic experience itself is meaningful. In fact, psychotic individuals often experience more freedom, instead of less, and they feel their consciousness is not troubled or darkened, but they report all kinds of experiences that are phrased with positive light metaphors. By defining psychosis basically as a certain lack, mainstream psychiatry and psychology imply that meaning, freedom, and truth are only found in the nonpsychotic way.

What philosophy has to offer here is an examination of both sides, an inquiry into those notions that are so often assumed to be absent in psychosis. Philosophy investigates the power and implications of the negative: for instance, in what world does the psychotic live, when it is claimed that s/he does not live in a real world? How is this supposed unreality experienced? Why does it often feel more real than so-called ordinary reality? And so on. Only by letting go of our own prejudices about reality and thought, about how language and meaning operate, may we gain a deeper understanding of other (psychotic) kinds of organizations, other kinds of being-in-the-world than that of the nonpsychotic individual.

To be sure, I do not have any principled criticism of the use of medication or cognitive behavioral therapy in itself. But the pretension that often accompanies the provision of effective treatment, that the clinicians know and understand what psychosis is better than the persons themselves—

 can have a negative impact on people’s lives. I mean, the reason why I receive a continuing stream of all kinds of emails and reactions from those who underwent psychosis, sometimes even more than 40 years after their psychosis, is significant here. If psychosis were really just like diabetes or a broken leg, a temporary natural disturbance of the mind, why would so many remain so puzzled afterwards? Why do they want to go back there, consciously or unconsciously? What is this mysterious, seductive quality of psychosis? Psychosis is not only a disorder. It is also the basis for thinking towards a different order.

: How do you think such prejudices can be avoided?

: It is not so difficult to avoid these prejudices. The essential thing is to drop the assumption that those who are called psychotic no longer have meaningful consciousness, are no longer competent language users, uttering meaningless sentences. This kind of prejudice may partly be overcome in psychiatric practice by not approaching patients with psychotic symptoms from a purely scientific perspective, with all its supposed application of evidence-based knowledge. Instead, we ought to engage with psychotic individuals as unknown human beings, who are basically thrown into the same puzzling world as yourself, a world in which we are entangled, which defines us, but which at the same time is defined by us, and in which we experience freedom.

In fact, psychopathological theories that start from this perspective are numerous, but no longer mainstream in our age. We may think of all kinds of psychoanalytic theories, phenomenological theories, enactivist theories, and so on. But the danger with any of these alternatives is (and that is due to the fact that it concerns scientific theories or models) that they reduce and categorize the psychotics again under just another determining and defining order, and treat them as having some kind of deviant mind, ruled by just another set of natural laws. A theory may be helpful for the first steps towards contact, but all too soon they become obstacles, closures of the mind, that prevent the soul from seeing another soul, outside of his own, outside of the theory.

Nothing in this negates or takes away from the fact that these individuals may be greatly distressed and impaired, and they may be in need of clinical care. To say that psychosis is meaningful is also not to deny that there are differences from ordinary states of consciousness. On the contrary, this difference and its exploration is what the whole engagement with psychosis starts with, both in psychiatric practice as well as in my book. There is a paradox here. There is simultaneously a continuity in experience between psychosis and non-psychosis, as well as a discontinuity, a definite break and identifiable difference, between psychotic and non-psychotic experience.

: How does this inform the philosophical approach you take in your book?

: My philosophical approach tries to avoid such theorizing. I do not seek to construct yet another theory about empirical patterns of behavior and thought in psychosis. Instead of a theoretical monologue about some scientifically well-defined object, my book is a philosophical dialogue between several undefined subjects. My book is essentially dialogical, notwithstanding the fact that many of its dialogues are internal dialogues. These dialogues represent a kind of dance, and sometimes a battle, between on the one hand the rational philosopher or curious researcher, and on the other hand, the psychotic, the madman—with inclusion of relatives like the religious zealot, the mystic visionary, and the nihilist skeptic, who in the course of the text change position. Meanwhile, it remains unclear who is leading, who is following, who is analyzed by whom, and who is stimulated by whom.

The knowledge or theory that my book might yield, and that might be transmitted to a reader, only emerges by following this dance from a starting point in a third position, that of the reader, who can only extract sense from my book when he or she is open for internal dialogues from within him- or herself. This dialogical character (some use here the term 

), by the way, is the basis for all philosophy. It is a way of essentially opening, disclosing, of bringing thoughts into the spotlight (also discussing this spotlight), of exploring hidden perspectives and possibilities. It is different than the closing character of scientific discourse, which is more interested in defining, reducing, ordering, and controlling. In this respect, my book differs widely from the methods and ends of psychological or psychiatric theories. Scientific discourse is successful when the theories and predictions are confirmed by observation in practice, and when these theories are implemented in new regimes of social order, psychological management, and action schemas. My book will be successful when the fundamentals of all regimes of order are suspended into disbelief during a momentary glimpse in the mind of the reader, and the reader is able to see that we all just dance in the void.

 (the snake that eats its own tail) and the 

 play a central role in your discussion of psychosis. Can you elaborate on the significance of this motif?

: The Mobius ring is indeed an important image. It helps me visualize an underlying motif in my book. Let me explain: Initially, in my book, there is a difference between, let’s say the meta-level, the thinker (philosophy), and the data, or object level (madness). On the theoretical meta-level with its numerous concepts, argumentations, and analyses, I try to make sense of the data: how do time and space change in psychosis, what happens to reality, the self and the other? This concerns Part One of my book, in which I present an introduction into the findings of phenomenological psychiatry, with help of philosophers like Edmund Husserl, PhD, Maurice Merleau-Ponty, PhD, Ludwig Wittgenstein, PhD, and René Descartes. At this level in Part One of my book, the front side of the Mobius ring, where the philosopher-narrator meets the reader, is clearly philosophy, and the (hidden) back side is madness. With philosophy as a tool, as a way of thinking, I try to capture something of that enigmatic hidden domain of madness. So far so good.

Then in Part Two the narrator, the philosopher notices that with this philosophical theorizing there remains a distance between 1) the meta-level of philosophy with its concepts and learned discourse, and 2) the object-level where madness rules, with its anxieties, delusions, ecstasies, and its word plays and other-worldliness. Then from Part Two on until the end of Part Four of the book, the philosopher converges closer and closer to the madman. The philosopher no longer stays on the firm shore of his identity and self-assured discourse, but embarks with the madman, in order to not only describe and explain madness, but to think/experience him- or herself what it is like to be psychotic. In other words, the philosopher engages in some serious (psychotic) thought experiments and becomes entangled in the same quagmires as the madman. In the end, the philosopher has become mad and has reached the other side of the Mobius ring, the back side.

So, the Mobius ring is hidden in the book, and also reflects my own paradoxical experiences. I was doing serious research as a philosopher about psychosis (in fact, a substantial portion of the first part of my book is based on the papers I wrote during that time) while having in the back of my mind the data of my own psychosis from 15 years before. Then during that study of psychosis, my philosophizing intensified, and philosophy led to madness, and madness emerged out of philosophy.

: Even since becoming familiar with your book, I have been wondering about the relationship between psychosis and philosophy.

: I would say so! In my mind, one way to approach it would be to treat psychosis as a method of inquiry into the nature of reality such that, at the end of it, something is revealed about the nature of the world and our existence. Another approach might be more negative. In this approach, psychosis by itself does not tell us what reality is, but it throws our everyday epistemic complacency into disarray. We can no longer trust our sensory inputs, our perception of space and time, our social instincts, etc, and this provokes a state akin to Cartesian doubt, where we can no longer take our ordinary understanding of the world for granted. With some poetic license and over-simplification, perhaps I can refer to these positions as the 

, respectively. Certainly, there can be all sorts of interesting combinations and variants of these approaches. Would you consider this to be a useful framing? And if so, do you lean towards a particular position?

: That is a very illuminating framing indeed, and relates to the power of the negative, that I referred to above. Let me comment on both positions and their relation to madness. In the original version of the Cartesian thought experiment, the one described by Descartes himself, a subject throws himself into full doubt, distrusts his senses, and searches within his own thought for a firm ground for existence, an undeniable truth, beyond all doubt. Descartes describes how in this process of radical doubt, everything is rejected because of its principled uncertainty, mutability, and transiency. The only thing that cannot be doubted, is that there is me, enveloped in a doubting process. And then from this elementary given, the famous rationalist adage follows, 

: “I think, therefore I am.” In the dark nights of the mad soul (compare for instance my autobiographical notes at the end of Part Two of my latest book), the individual with psychosis may have an analogous thought process, and he or she may end up in a kind of intellectual and existential despair, driven by radical self-doubt. But this despair may also take the form of an experience of perplexity about the undeniability and givenness of one’s own existence. The argumentative structure in Descartes’ texts shows similarities with the existential doubts the madman is in.

What is often forgotten in popular considerations of Cartesianism is that building on 

, Descartes goes on to prove the existence of God as well as reality, using arguments that are today seldom accepted as self-evident truths. Descartes draws the conclusion that from being able to think an utterly perfect being (God), we must conclude that this utterly perfect being exists, otherwise it would not be utterly perfect. Now the madman may in myriad ways follow, mirror, and deviate from such ways of thinking, and may get fully lost in all kinds of imaginations that are very difficult to understand for an outsider. However, when we are aware of these philosophical problematics and this basic scheme of Cartesian reasoning, we might come a little closer to some understanding.

Of course, there are also many differences between the Cartesian and the mad thought experiments. An important difference is that for Descartes this was simply a thought experiment, an epistemological exercise, but for the madman the radical doubt is a serious matter; he is drowning existentially, losing all firm ground, and desperately searching for an anchor. We might say indeed that Descartes performs an epistemological experiment, while, following the ideas of the Dutch psychiatrist and philosopher Antoine Mooij, PhD, the psychotic is involved in an ontological experiment.

Let’s look at mysticism in comparison. In the older days of Christianity, mysticism was an intellectual and theological way to argue, to contemplate, to pray, to envision, and eventually to experience awe at the greatness and the power of the Almighty God. Then there was no essential difference between mysticism, theology, and philosophy. It was only much later that mysticism became associated with visions in the West, in an epochal historical change in which visual hallucinations also became ascribed as a dominant characteristic of psychosis. Just as I stress the partially passive, experiential character of the active Cartesian doubt experiment, I view mysticism as a more active and intellectual undertaking than it is usually considered to be. The usual distinction made between active thought and passive perception (and their counterparts in psychopathology, delusions versus hallucinations) is too rigid, and it is in mad philosophy and philosophical madness that we see a continuing doubting of both, and a crossing of the separation between them, by way of the viability and flexibility of language signs and experience.

To come back to what you said, a kind of claim, or at least, something that is often argued for, is that within mysticism [quoting you:] “at the end of it something is revealed about the nature of the world and our existence.” Now, what I demonstrate, especially in the second part of my book (called 

), are the analogies between such a mystic path that seeks revelation, and the psychotic rollercoaster, that also traverses a world where things are revealed, signs are given, and the transcendent sacred, as well as its dark counterpart, the horror, seem to become immanent. It is then as if you have found a way out of the restricted ego or self, out of your own private thoughts, your historically accidental mindset, towards an outside, a real, that presents itself as more real than anything, and that consists of both good and evil forces, both personal as well as mechanical and impersonal. I use this mystic path, with its semireligious language, to shed light on a range of terms and kinds of discourse that we also find in psychosis, like 

I argue that there is a lot of overlap between what is going on in that spiritual branch of experience and language, and what is going on in the psychotic world. But I never argue, not in my book, neither anywhere else, that there is a special secret path towards truth, and towards ultimate knowledge of reality. Nor do I argue that the mystic or the madman are simply affected by a 

. To understand what they/we/you say in various kinds of exalted, psychotic, spiritual language, it is just not enough to assume that the psychiatrist knows beforehand what kind of language game, and what kind of experience, is at stake in a conversation with a psychotic.

I understand the daily, down-to-earth problems in psychiatric practice, so it is not the actual practitioner my criticism is aimed at. Instead, it is aimed at those who pretend to have insight into the deepest questions and perplexities about reality, meaning, language, and who from there then judge that other individuals’ ways of expression are nonsensical or illogical. Here lie also further social and political implications: What voices have the right to expression and to be part of the common world of sense and meaning, and what kind of communication and interaction is deemed to be sick, meaningless, illogical, psychotic, and is therefore given no place in the space of reasons

: From a phenomenological and philosophical perspective, does it matter what the source of, or the cause of, the psychotic experience is? For example, does it matter that psychosis is a result of substance intoxication or a result of metabolic delirium? Or does any psychosis, regardless of origin, offer the same possibility to explore philosophy? In other words, is the philosophical value of psychosis independent of the etiology of the psychosis?

: Yes, it does matter, but not for everybody. Let me give an analogy here. Suppose we are all used to and educated within a tradition of classical realist paintings. And then we meet this quite varied but troublesome group of modern paintings, some recognized by us as art, but others, we just do not know what they mean. We suspect some of them to not be paintings at all, but canvases on which paint has been randomly thrown, a kind of fake Jackson Pollock. In addition, consider that the painters of some of these paintings acknowledge an inability to paint in a realist way. They miss the right brushes, do not have the right paint, are not skilled in painting, or do not have proper motor control over their fingers. However, we will not be able to determine whether the painting is problematic (and if it is, the exact nature of the problem), simply by examining the paint, because it is always possible that what appears to us to be failures of the artistic method are deliberate and perfectly executed works of art. The meaning and value of the famous 

 painting, cannot be reduced to properties of the paint or the finger movements of the painter. This distinction between levels is so easily grasped when discussing art, but so often not understood or forgotten when we talk about the life of the soul in madness. In other words, the material (the neurobiological dimension) is of course an important aspect of psychosis, just like the brushstroke technique or the choice of paint are important aspects of painting. I am more interested in the history and meaning of art than in the artistic skill of painters or in the chemical analysis of paint.

I do not think in terms of hypotheses of causation with respect to psychosis, but only in terms of plausibility of interpretations. There may be facilitating circumstances that bring individuals into various states of madness and psychosis. These facilitating circumstances can be anything, from using of certain drugs, to having a traumatic childhood, to having a certain neurobiological disposition, to having been in war, to abruptly losing a significant other, to living in socially and culturally painful and oppressive circumstances, and so on, and so on. But what I am interested in is not the explaining of the illness, but the understanding of the individual, and his or her ontological position. And in that latter exercise, we must follow the individual with psychosis down the rabbit hole of those fundamental questions.

: How do you approach the experience of delusions, which on the surface represent the antithesis of philosophical thinking? Instead of an on-going grappling with a confusing reality, in the case of delusions we see a closing down of inquiry, resulting in what has traditionally been described as a fixed, false belief, unshakeable in the face of reasoning or contrary evidence. Perhaps it is only after the delusional force of the beliefs has dissipated that we can begin to philosophically understand the meaning of that experience?

: I think that delusions in the way you describe them here are only one side of the delusional story. Unlike many superficial cognitive accounts of delusion, I think that so-called delusions are better analyzed as reactions to an underlying, and temporally preceding, delusional mood, which is in fact also the position of most phenomenologists as well as psychoanalysts. A famous adage of the latter is that delusions are not the problem, but they are instead the first attempts to express and deal with another problem, of a quite different order. Nevertheless, I fully agree that a philosophical understanding, in the common understanding of this phrase, can only happen 

. A self-understanding and a philosophical elaboration that is intelligible to others, communicable in common language, must handle and circumnavigate the seduction to remain trapped by the awe for the ineffable, both in its ecstatic as well as despairing forms. The paradox of any such understanding, including mine, is that with this understanding, the thing itself, the psychosis, is in danger of retreating beyond the horizon. And this same striving towards understanding may attract and provoke psychosis to rise up again from the invisible. I know that some readers of my book put it down, but then had to resist being drawn back towards that enigma.

, you say at one point: “Philosophy never promised you a rose garden, neither do I. Furthermore, it could well be argued that there is some kind of antihuman tendency in extreme philosophical and psychotic thought. Both philosophy and madness may have intense ‘superhuman’ or ‘a-human’ powers that burn anything substantial, anything meaningful, away into a hole of nothingness. But, well, the interests of life are not necessarily those of philosophy.” Can you comment more on this misalignment between the interests of life and the interests of philosophy/psychosis?

: Most modern philosophy starts from and leads back to common sense assumptions. Many are rooted in the Age of Enlightenment and have the overt values of modern society as their implicit background. They assume that what is argued by human thought (including the findings and results of philosophizing) are and should be beneficent for (human) life. We find that assumption under all kinds of moral and political philosophies, but also under so-called philosophy of psychiatry. However, it is not so obvious that philosophical thought should lead to beneficial effects on society or the individual.

There are a range of extreme critical philosophical views, such as views of ultra-conservative, nationalist, racist, antihumanist, transhumanist, and even antinatalist nature. While some of these views are considered dangerous to society, they still remain sustained within a broadly defined space of reasons, although this may be contested by others. Some philosophical ideas go even further and have the paradoxical capacity to be self-undermining for the thinker who thinks them. They may be detrimental to what we usually consider the space of reason; they are contra (human) life. That is, they argue in quite sophisticated ways that 

. They use notions of emptiness, the void, and nothingness, not to draw positively flavored, so-called 

 conclusions, but only to affirm annihilation, death, suicide, destruction, and (auto-)extinction. Such philosophies can be seen as a variety of nihilism (although this term refers to a much larger range of philosophies) with important names such as Friedrich Nietzsche, PhD, of course, but also Emil Cioran and especially Ray Brassier, PhD, with his devastating book 

. Just being against life does not mean that these ideas are untrue or can be excluded from the realm of philosophical thought. When we take philosophical thought seriously, we cannot reject conclusions just because they do not fit our restricted human-centric point of view. That is what I mean by saying the interests of life are not necessarily those of philosophy.

In the context of the relation between psychosis and philosophy, this is important to consider, and this also sweeps away all romantic humanist notions of both philosophy and psychosis. Consider the case of someone like Anders Breivik, the Norwegian terrorist and right-wing extremist. Some particular philosophies or world views, as well as some particular forms of madness, are thoroughly destructive and devoid of good intentions. They are closer to the darker variety of the mystical aspect of madness. American philosopher William James, MD, described it as 

In delusional insanity, paranoia, as they sometimes call it, we may have a diabolical mysticism, a sort of religious mysticism turned upside down. The same sense of ineffable importance in the smallest events, the same texts and words coming with new meanings, the same voices and visions and leadings and missions, the same controlling by extraneous powers; only this time the emotion is pessimistic: instead of consolations we have desolations; the meanings are dreadful; and the powers are enemies to life.

In such cases, the philosophical aspect of the psychosis would not only consist of the strange ineffable character of an experience filled with awe and puzzlement, but also of an intra- and interpersonal struggle between life-affirming forces and life-denying, a-human or antihuman forces. The implicated question is whether we must eradicate such poisonous ideas, or must we taste and experience them ourselves, to examine the enemy, and immunize ourselves against them, with all kinds of risk of contamination? The implicated practical problem for psychiatrists is to make responsible decisions in matters that comprise both philosophical, theological, as well as political complexities. What is demanded of the psychiatrist here has hardly anything to do with scientific knowledge, is also difficult to be captured in ethical guidelines, and can only be referred to with notions like prudence.

: Something that has struck me watching how various individuals engage with you on various platforms is that there appears to be a desire (conscious or unconscious) on the part of your many interlocutors—I would not consider myself immune either!—to co-opt your views for their own agendas, and there are certainly many competing agendas vying for power, resources, and respectability in the mental health arena. Is this something you are also cognizant of? If so, how do you feel about being thrown into this state of affairs?

: Yes, I know. When I wrote my book, I had in the back of my mind a reader like myself, but then many years younger. I wanted to show where thought may lead you, what the extremities of existence and experience are, and what the attraction and the repulsion of madness (and philosophy) are. Whereas Thomas Nagel, PhD, titled his famous paper on consciousness, “

,” I wanted to write a “What Is It Like to Be Mad?” The only thing I strongly oppose is the idea that everything that is said, everything that is experienced in psychosis, would somehow be unreal, epiphenomenal of a sick brain, illogical, and so on. This does however not imply that I would defend some kind of alternative theory of psychosis—not psychoanalytical, not phenomenological, not antipsychiatric. I am simply not interested in making theories about psychosis when these do not somehow also contain dialogues with psychosis. I give advice and courses about psychosis and philosophy to all kinds of professionals and nonprofessionals in the Netherlands and Belgium, and I do not have a kind of ideological or philosophical stance about what the world is, what psychosis is, and how psychiatric practice should be. I prefer to think and talk more about what is going on in madness than about the best way for the professionals to do their work, although the latter is often a theme that results from considerations of the former.

: You have warned against romanticization of psychosis. From what I can tell, while you seem to be in favor of controlled explorations of psychosis by means of philosophy or mysticism, you do not seem to wish the clinical, raw experience of psychosis upon anyone. While you have derived insights from your experience of psychosis, I imagine that you are also glad to have come out of psychosis. How do you think we can reconcile the tension, to the extent that it exists, between the clinical and philosophical attitudes towards psychosis? Individuals with psychosis are often tremendously distressed and impaired, and they typically require some form of clinical care to help navigate this distress and impairment. How do we reconcile this with the romantic image of the madman as a misunderstood mystic or an unrecognized philosopher or with the more prosaic image of a deviant whose deviance has been pathologized?

: I think that the clinical attitude should incorporate the philosophical attitude, and clinicians should be educated in this. In fact, [laughing] I would recommend that they should all read my book, or perhaps follow the 

 I teach about my book! In my book, they would indeed meet these images of the misunderstood mystic, the unrecognized philosopher, and the pathologized deviant. However, my book does not want them to accept these images as the essence of psychosis, but as starting points from which a dance, dialectic, or conversation may begin between philosophy and madness, the rational and the irrational, without being condemned to one position or the other.

Dr Aftab has no relevant financial disclosures or conflicts of interest. Dr Kusters receives royalties from the sales of his book and generates income from the online course he offers on his website.

. The Varieties of Religious Experience: A Study in Human Nature

Critique of Pure Madness: Wouter Kusters, PhD

Janice Haaken, PhD, is professor emeritus of psychology at Portland State University, a clinical psychologist, and a documentary filmmaker. Dr Haaken has published extensively on psychoanalysis and feminism, the history of psychiatric diagnoses, interpersonal violence, the social psychology of remembering and storytelling, and documentary methods. Her books include

 Pillar of Salt: Gender, Memory and the Perils of Looking Back

Hard Knocks: Psychology and the Dynamics of Storytelling

Psychiatry, Politics, and PTSD: Breaking Down

 (Routledge, 2020). She has directed 6 feature films: 

Queens of Heart: Community Therapists in Drag

Mind Zone: Therapists Behind the Front Lines

Milk Men: The Life and Times of Dairy Farmers

Necessity: Oil, Water and Climate Resistance

. Dr Haaken has received numerous awards for her filmmaking, most recently the Lena Sharpe Persistence of Vision award at the 2019 Seattle International Film Festival.

 is a fascinating critical analysis of posttraumatic stress disorder (PTSD) as a diagnosis, the turbulent debates surrounding the role of trauma in psychiatry that led to its creation, and the institutional and sociopolitical functions it serves in a wide variety of settings such as the military, veterans’ affairs, war zones, refugee camps, and criminal justice system. I was impressed by the adeptness with which Dr Haaken tackles the ambiguity, uncertainty, and the internal contradictions present in the subject matter while resisting the temptation for simplistic answers. This interview delves into some of the broader conceptual and sociopolitical issues surrounding PTSD and psychiatric diagnoses discussed in the book.

: You wear many different hats (psychoanalytic clinician, critical psychologist, documentarian, and field researcher), which offers you a unique advantage in being able to approach psychiatry from a variety of different perspectives. Can you tell us more about your background and how that has influenced your critical inquiries?

: My first professional career was in psychiatric nursing, beginning in the early 1970s as a staff nurse in a treatment program for children, and later in medical training centers in California and Oregon. My nursing background was formative to my identity as a professional, even in the course of pursuing a PhD in clinical psychology. Nursing is a traditionally female job, but one that is very hands-on and close to bodily experienced suffering. I value that. As a clinician, I was influenced early on by the women’s movement and its rejection of a lot of the old diagnoses, with hysteria the prototypical example. I have always approached the diagnostic process as a form of storytelling that requires attentiveness to social contexts of mental suffering and to the language available for communicating distressed states. In addition to feminism, I was influenced by the radical psychiatry, critical psychiatry, and the antipsychiatry theories of the 1960s and 70s, all of which shared a critique of the medical model that underpins psychiatry.

When I joined the faculty at Portland State University, my research methods—grounded in critical theory, psychoanalytic-feminism, discourse analysis, and qualitative field research—were considered quite radical, although the department moved to incorporate more qualitative methods over time. I joined the faculty in the era when academic psychology was moving in a more applied direction. During the year that I joined the faculty, the animal lab (which took up an entire floor of our building) was in the process of shutting down. My department was migrating to field studies and taking up messy data and real-world problems that were central to my own program of research. My documentary films grew out of my field studies where initially I used cameras to capture more of the communicative language of participants than audio recordings permitted.

. What did you set out to do and where do you think you ended up in terms of your analysis?

: This new book extends a line of analysis pursued in 

Pillar of Salt: Gender, Memory, and the Perils of Looking Back

, a book that focuses on narrative aspects of psychiatry and how social movements shape diagnostic thinking. In the later decades of the 20th century, trauma disorders, from multiple personality disorder, dissociative identity disorder, to posttraumatic stress conditions, gained enormous currency in the mental health field. There were intensely heated debates over a widening array of symptoms thought to be disguised symptoms of trauma.

, I revisit some of those debates and the historical and cultural dynamics that shaped the way trauma models took hold late in the 20th century. With the rise of neoliberalism, and the push to marketize everything in sight and the dismantling of public services, the dramatic and morally charged accounts associated with trauma represented an effort to break through the high threshold for responding to more mundane forms of suffering. With PTSD narratives, I was interested in how this diagnosis migrated through this same era and how the scientific disputes over the diagnosis seemed to be symptomatic of a deeper problem in the field. I came to think of PTSD as a forensic diagnosis as it was used in settings where clinicians were enlisted in adjudicating the fates of individuals. There is some consensus that PTSD is a redemptive diagnosis in the sense that it assigns causality to an external force and does not implicate the sufferer. Many progressive clinicians embraced the expanded use of the diagnosis because it seemed to offer a form of sanctuary or protection from more damning labels. I was interested in what was excluded in the differential diagnostic process as clinicians were using this diagnosis, and particularly in the military and the Department of Veterans Affairs (VA), the courts, and other institutional settings.

: It was fascinating for me to read in your book about how the diagnosis of PTSD emerged from a union of research studies in stress and trauma, and how different the cultures of these traditions were. Stress research had adopted a very mechanical view of psychology, as you point out in your book: “People, like machines, are subject to breakdown under conditions that exceed their operational capacities.” While on the other hand, “To speak of psychic trauma is to position the problem within a moral community of responsibility as well… Whereas stress speaks to the machinery of mind, trauma evokes images of the ghosts in those machines” (p. 8-9).

 How do you think this tension has played out in subsequent research on PTSD?

: Early in my career, I was highly critical of machine metaphors, associating them with masculinist assumptions in science and dehumanizing modes of intervention. My own field of feminist psychoanalysis holds some affinity with the trauma models in their focus on storytelling, and the ghosts in the machine! Trauma therapists often speak of hauntings, which can be a meaningful way of representing the ineffable or elusive aspects of mental disturbances. But I do think it is a mistake to align metaphors too readily with conventional gender dichotomies, or good vs bad metaphors. The Yerkes-Dobson law, for example, developed by military psychologists during the First World War, is based on what could be described as a machine-model of stress and it remains the closest thing we have to a natural law in psychology. It still explains some aspects of the relationship between increased stress plotted against performance and breakdown. But military psychologists soon realized that the model failed to account for the complex dynamics and factors that mediate stress responses.

How should the sociopolitical nature of PTSD as a diagnosis inform our understanding of trauma?

Awais Aftab, MD

Articles

The Neurodiversity Paradigm in Psychiatry: Robert Chapman, PhD

Critique of Pure Madness: Wouter Kusters, PhD

Trauma and the Politics of Diagnosis: Janice Haaken, PhD

From Classic and Critical to Integrative Psychiatry: Dan J. Stein, MD, PhD, DPhil

Exploring the Evolution of Depression

Global Psychiatry’s Crisis of Values: Dainius Pūras, MD

Psychiatry and the Long View: Paul Summergrad, MD

Reconsidering Care and Coercion in Psychiatry: Kathleen Flaherty, JD

10 Meditations on a Virtuous Career

Phenomenology, Power, Polarization, and Psychosis