Monday, 20 February 2017

Agency in Madness

I have a piece in the March edition of The Psychologist on the history of thinking about agency in psychosis. It is meant to be a brief whisk through of some of the literature (fictional and psychiatric) on the issue.

However, there is an intriguing conundrum nearby that I don't really get into: the question of whether it is actually possible to think yourself into a psychosis. If, like me, you are tempted to answer "no," then it is worth wondering why. Two obvious thoughts: 1. Psychosis seems, at least in part, to be a matter of predisposition. 2. Most people experience psychosis as something that happens to them. But these are not knock down arguments

First, a predisposition needn't entail something's being entirely passive. Many talents are probably (partly) a matter of predisposition, but you can't express a talent without agency. Does it ever make sense to say that someone has a talent for psychosis? Second, experiencing something as though it were passive is not the same as its actually being so. We can be mistaken about mental agency, as psychologists well know.

Part of why this question is interesting is that the non-standard answer (the one that violates our traditional intuitions) would seem to vindicate some peoples' experiences. I once asked someone in the recent aftermath of a psychosis how they had found their antipsychotic medications. Did their thinking feel clearer? It certainly seemed (from the outside) as though it was. They agreed their thoughts were clearer, but disavowed a role for the medicine, saying they had done it themselves.

Medication in this instance looked like the most plausible proximal cause, but if psychosis is more likely to emerge under certain cognitive conditions, might it be that medications provide the conditions, and that the patient does the rest? Outcomes in psychosis are very variable. Could agency be an overlooked piece of the puzzle?

1 comment:

  1. Interesting topic about agency and madness. Coming from the field of dual diagnosis, I've come to think of questions of agency as central both to understanding trajectories of patients as well as understanding the prejudice against dual diagnosis patients among professionals.
    I will allow myself to share some thoughts on this.
    First the question of agency is deeply embedded in discussions between a psychiatric (mainly biologically and deterministically oriented) and a psychological (more humanistically and volitionally oriented) position. Dual diagnosis such as psychosis spectrum disorders and cannabis use is an uncomfortable fit: psychosis is seen as a mainly genetic bottom-up process, whereas substance abuse either explicitly or implicitly is seen as a weakness of the will/a problem of agency. Perhaps partly because dual diagnosis straddles two different frameworks for understanding human behavior and experience it creates uneasiness especially in the collaboration between the agencies responsible for treating these complex patients (primarily psychiatry and substance abuse treatment - at least in a danish setting).
    Secondly there is no good understanding of what agency is in the first place - neither in the 'normal' population nor in a 'psychiatric' population. In neuroscience - it appears to me - there is very little room for volition, so to speak. And if you have had daily business in a psychiatric hospital you will probably have noticed, that the personnel readily shift the degree to which they ascribe agency to the patients. At times odd behavior is described as 'the disease' but at other times more volitionally informed accounts are readily shared. This is also well documented in anthropological accounts of psychiatric practice.
    Thirdly the question of 'psychogenic madness' suffers from a lack of appreciation of how interconnected not only mind and body are but also mind-body and ecological niche. Even small volitional actions can set in motion complex feedback-processes involving what might be termed the mind-body-environment complex. If we allow for even minimal agency this potentially can set in motion complex processes that may lead to extreme situations resulting in madness.
    My position so far is that the question 'can you think yourself mad' neglects that thinking is never decontextualized but is always embedded in continuous feedback processes and this severely questions the idea of linear causation implied by the question. But probably thinking and a lot of other simultaneous stuff going on can lead to states we term 'madness'. I think we need to look to systems science and ecological models to start scratching the surface of this complexity.