Mad by Design: An Ancient Paradigm of Psychiatric Thought

To propose that madness may have a function is not to deny the toll it may exact on people, but to help us understand what problem it is meant to solve.


There would appear to be a 2,500-year-old medical consensus that madness stems from “the three Ds”: disease, defect, dysfunction. The Hippocratic author of On The Sacred Disease informs us that all forms of madness arise from excessive heat, cold, moistness, or dryness in the brain.

Echoing the Hippocratic text, the Diagnostic and Statistical Manual of Mental Disorders of 1980 tells us that all mental disorders stem from “behavioral, psychological, or biological dysfunction[s].” And Thomas Insel, one of the founders of the RDoC system of mental disorder classification, declares that “mental disorders can be addressed as disorders of brain circuits.”

I call this paradigm—this style of thinking and seeing—madness-as-dysfunction. It begins with a conception of how a person is supposed to behave, to think, and to feel, and it sees in mental disorders a deviation from this correct path. In some ways, madness-as-dysfunction is so entrenched in contemporary psychiatric thought that it can be hard to find one’s way out of it.

But madness-as-dysfunction has always had its dissenters: thinkers and theorists who, instead of seeing madness as a defect or disease, see it as having a function, goal, or purpose. Madness can be a designed response to the trials of life, like getting calluses because of friction, or tanning from exposure to the sun.

The purpose of my recent book, Madness: A Philosophical Exploration (Oxford University Press, 2022), is to carry out a recovery mission. It seeks to recover this ancient paradigm, to name it, and to show how it forms a robust alternative to the dominant medical view. I call this tradition madness-as-strategy, or alternatively, madness-as-design. My goal is not to replace madness-as-dysfunction, but to make an intellectual space for a different way of seeing, and to show how this way of seeing has always been part of psychiatric thought.

Photo of a face painted, glowing in ultraviolet light

Voices of Dissent

To flesh out the idea of madness-as-strategy, we can consider several examples of how it shows up in medical theorizing in different eras. Luminaries like Robert Burton, in his bizarre and brilliant 1621 volume, The Anatomy of Melancholy, describes madness as a tool that God uses to reform the wayward soul. Writes Burton, “[God] is desirous of our salvation…and for that cause pulls us by the ear many times, to put us in mind of our duties.”

In the same vein, George Cheyne, in his 1733 The English Malady, depicts melancholy as designed for a purpose: God gives us melancholy to warn us when our lifestyles begin to stray from his divine ends. The art of healing begins when we can pinpoint exactly what purpose God has in mind.

In the nineteenth century, secular thinkers continued this tradition of thought, now freed from its religious overtones. The German physician Johann Christian August Heinroth—the first chair of psychiatry in Europe—wrote in his monumental 1818 textbook of psychiatry that certain forms of insanity are coping strategies, not diseases or defects. They’re devices that people unconsciously use to buffer themselves from the pain, rejection, and humiliation of reality:

“In a life which has been depraved by neglected education, circumstances, and guilts…a moment may come when the measure is full and runs over, and the imagination becomes strained to the limit in trying apparently to effect a full compensation and to transform the evil fate as though by the touch of a magic wand.”

He thought the best remedy was to allow the illness to run its natural course.

The philosopher Arthur Schopenhauer, in his The World as Will and Representation of 1819, also envisioned madness as a flight from a cruel reality: “if such a sorrow, such painful knowledge or reflection, is so harrowing that it becomes positively unbearable, and the individual would succumb to it, then nature, alarmed in this way, seizes on madness as the last means of saving life…”

Philippe Pinel, the moral reformer who supposedly broke off the chains of the mad patients at the Bicêtre hospital in Paris, thought that some forms of madness possessed a healing or “salutary” power. In his 1801 Treatise on Insanity, he tells us that attacks of mania (accès de Manie) should be allowed to run their course in a safe and non-threatening environment. For Pinel, understanding the healing purpose of these episodes was crucial for therapy: the wise healer knows when to trust the “salutary efforts of nature” to heal the patient, rather than drugs, leeches, and vomiting.

Freud, too, saw purpose and function, rather than mere pathology, in the mental disorders of his day. From very early in his career, starting with his “The neuro-psychoses of defense” of 1894, he sought to show how hysteria, obsessions, and even psychosis should be seen as unconscious, goal-directed attempts to fulfill a forbidden wish. Freud constantly reminds his readers that much of what modern medicine deems pathological is actually goal-directed and adaptive.

Consider his 1911 paper on Judge Schreber, the “Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides):” “And the paranoic builds [his world] up again, not more splendid, it is true, but at least so that he can once more live in it. He builds it up by the work of his delusions. The delusional formation, which we take to be the pathological product, is in reality an attempt at recovery...” Psychoanalytic theorists such as Frieda Fromm-Reichmann and Harry Stack Sullivan sought to continue this tradition well into the twentieth century.

The physiologist and philosopher Kurt Goldstein gave voice to this tradition in his The Organism of 1934. Goldstein thought that many of the psychiatric problems that he encountered among “shell-shocked” war veterans were not mere byproducts of nerve damage. Rather, they were adaptive, functional, compensatory responses to that damage: “Deeper insight into the nature of neuroses, as well as brain lesions, has shown us that deviations from the norm are not always signs of disease. On the contrary some of them belong to the processes in the patient that protect him from certain dangers naturally involved in the change to a new normality.”

A Recent Renaissance

This alternative tradition, madness-as-strategy, never came to an end. Today’s evolutionary psychologists, like Vivette Glover, Martin Brüne, and Randolph Nesse, are inclined to see mental illnesses such as depression, the anxiety disorders, or even the delusions of schizophrenia, as having evolved purposes. They exist today, and have the form they do, because of how they benefited our prehistoric ancestors—and perhaps how they continue to benefit us today. Consider depression, which Nesse hypothesizes to be an adaptation for detaching from unrealistic life goals, or generalized anxiety disorder, which Glover describes as an adaptation for making us vigilant to potential threats.

This design perspective has even infiltrated neuroscientific research: consider the enhanced perceptual functioning theory of autism, which holds that some features of autism result from the enhanced, rather than diminished, functioning of brain areas involved in various cognitive tasks. By the same token, neuroscientists Peter Uhlhaas and Aaron Mishara argue that delusions of schizophrenia might serve a function, namely, to provide the person with a coherent framework of ideas that help her to continue operating in society.

Putting madness-as-strategy into our theoretical vocabulary has fruitful consequences for the history, philosophy, and practice of psychiatry. It gives historians a new way to think about the past. It gives philosophers a new framework in which to contemplate the very meaning of “mental disorder.” It can also impact methods of treatment: for example, as Rosa Ritunnano and her colleagues show in a recent issue of JAMA Psychiatry, the madness-as-strategy paradigm can impact how we approach delusions, by helping us understand what problem they are meant to solve.

Perhaps most importantly, however, madness-as-strategy can contribute to the task of building an intellectual framework for Mad Pride, mad resistance, or mad activism. This movement is helmed by mental health service users and ex-patients who demand that society adopt new forms of conceiving of, and engaging with, madness.

Madness-as-strategy helps us rethink madness outside of the “three Ds”—defect, disease, and dysfunction—by allowing us to glimpse, in some mental illnesses, a positive meaning or purpose. It also shows us that this approach to psychiatry—the approach that sees purpose and goal-directedness rather than disease—isn’t a recent fad, but part of a tradition with a rich, though largely forgotten, legacy.

To propose that some forms of mental illness have a function or purpose is not to deny the terrible toll they sometimes exact from people who suffer from them. Nor is it to deny that brain disease can sometimes have psychiatric consequences. Rather, it is to encourage us to simply raise the question of whether some disorders should be seen as features, not bugs—and to shape one’s treatment with that premise in mind.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. Though these two paradigms both have some degree of validity, the medical model that focuses on the brain and nervous system is the most limited, while the one that focuses on mental processes is less limited.

    They still do not cover the entire range of possibilities. Another old paradigm was “demonic possession” which was one ancient attempt to fill in the gap. Yet another ancient spiritual teaching involved the concept of karma, which explained this-life suffering as a result of unresolved conflicts from previous lives. These all in fact have some validity. And I don’t think we should rule out any paradigm simply because it could be used as a justification for mistreating the “mad.” Many in this field will find reasons to lord over patients regardless of how well we understand what makes them suffer. After all, it is mainly this irrational desire to suppress others that is the cause of all these problems in the first place.

    If people are getting into the mental health system for being merely a bit delusional (like Elwood Dowd in Harvey) or depressed – a very common response these days to the pressures of life – then we are back to our basic criticisms of the current system which seems to operate as a con game constantly looking for new “marks.” But there are many people who have experienced “mental illness” as real suffering or a genuinely confusing experience. They seek out the mental health system hoping for real relief, not a label and a bottle of pills. To help such people, all the paradigms of “madness” must be brought to bear and each cause properly identified and properly treated. In an ideal world, the being itself would be able to treat itself. But we don’t have an ideal world. We struggle every day just to find what’s left of our own humanity.

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    • Beautifully illuminated.

      I would say also though that there is a collective function of madness, in the way a crowd stirs and seethes and shakes up into chaos. It becomes uncontrollable, by “logic”, perhaps the rationalism from the traditions.

      But the unusual thing in this era is the way “logic” in psychiatry, promoted itself via the acceptance of designations of madness. This has made the crowds awkward about seething out of control and becoming freed by madness, lest they look…. well ……mad.
      So instead they have been more inclined to fight fire with fire by fighting “logic’s” imposition of control with retorts that are just as “rational”. But this leaves madness out in the cold. The joy of madness and the healing found in madness as a remedy and riposte has to be put away. Like putting away childish things. But this then moves “logic” from psychiatry over to antipsychiatry. And since “logic” is how humans bully and control each other’s “free choices” it could mean antipsychiatry grows enamoured with rationally “making sense” far more than “making love”.

      To sound a bit Hippie there.

      Since antipsychiatry might not see the relief of being mad as seeming like anything other than “proving psychiatry correct that everyone is dim”, antipsychiatry could become rigidly the opposite of lovely collective madness. Even though there is a great deal of healing to be discovered in madness, individually and collectively. This is because madness aligns more “with feelings”. That is why “logic” finds the mad threatening to its neurotic need for neatness.

      But any society will go through growth phases where either there is too much “logic” stiffening civilization with rules so that nobody can speak or move, or society is cavorting and collapsing into in a cheerful Woodstock mud bath of “emotion”. It is like breathing….breathe logic in for five years…breathe out feelings for four….breathe logic in…..breathe out feelings. But “logic” is a bit of a breath holder until everyone is blue in the face.

      In the cross over there can be a melee of besuited activists. These words do not seem to belong together. Feelers wearing the badges and trappings of logic. It is all over social media. Millions of madness campaigns that are still pushing “facts, facts, facts” and “data” and “proof” and “evidence”, so that the old “logical” traditions being poked by proof will cave in and exhale. Yes, campaigns do need it! They need a bit of “logic” to spar and dialogue and stop the damage that “logic” does when it has grown devoid of all contact with “feeling”. Bad treatment needs stopped and if everyone is too wonderfully mad to pick up a phone it will not. But what I am always driving at is “balance”.

      By the way it is not that I do not like suits. I do. And it is not that I do not like “logic” and rules and order. I do. It is that I do not like deceit. It is not necessary.

      I am away to divert my madness towards Jamie in Outlander.

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    • Sorry I’m just getting to this! I agree that as a rule, “more paradigms are better than few.” Some might say “but what about the demon possession paradigm?” Columbia psychiatry prof. Richard Gallagher is a Catholic and an exorcist who is convinced that it’s a valid paradigm, and that a *very small* number of his patients are struggling with literal demons. We don’t have to get into the truth of demons to conjecture that it might help some suffering patients, particularly those who share his faith.

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      • I want to comment that this is indeed a valid phenomenon that may be causing undue upset in some people.

        Though exorcists take a very narrow-minded Biblical approach to this problem, others like Simon Parkes are more aware of how many different forms or “possession” or “harassment” are actually possible.

        I have even seen it in my community, where a trained person once ran into a baby that was being bothered by a disembodied spirit. He could only tell this was going on because he had developed his spiritual awareness to the point where he could communicate with that spiritual being.

        The point is that an expanded horizon of possibilities will lead to an expanded number of workable therapies. If those therapies are well-tested and not simply sold as “miracle cures” by grifters, then the cause of mental health could be advanced.

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  2. Well. myself and others have experienced the world going mad around us this last two years!! In fact today I heard a journalist mention a psychiatrist being interviewed on Del Bigtree’s show when asked what it was like for him going outside in NYC in ‘lockdown’, and he said it reminded him of his first experiences as a psychiatrst in a locked ward!
    I now have a feel what the times of the witch-hunts must have been like and am researching the comparisons! This is when everyone around you, even sadly family and friends become totally irrational. One thing I have learned, and still am, in these insane times is about the Germ Theory, and how the medical model is based on the theory of how there are germs and viruses always at the ready to attack us, and therefore we must trust the doctors to protect us with drugs and vaccinations. BUT there is a big problem with this, and that is that there is no actual scientific evidence for the isolation of any virus, and yet the whole world was shut down, people bullied to wear masks via relentless propaganda from the the mainstream, and social media and the politicians, and then everyone being cajoled, bribed and bullied to take experimental injections, and any questioning of all this, especially the injections, faced (and still does) you with censorship, and even people being harmed from the injections of losing loved ones are censored for talking about it in the media both mainstream and on platforms like Youtube, Facebook etc.. Meanwhile the drug companies, doctors, politicians etc deny any connection regarding injections causing harm and death!
    Now as well as The Germ Theory, I found out about Terrain Theory, and this is where I see correlations with the whole mental illness myth. So, for example, people explaining this like Drs Andrew kaufman, Tom Cowan, Stefan Lanka, Sam and Mark Bailey, Amanda Volmer etc will tell you that what Virology calls ‘isolation’ is not what the word means which would mean isolating a virus so as to study it. THEY mean a claiming the ‘virus’ is in a stew they make from various substances, and then further claim ‘the virus’ is causing the death of cells. But Dr Stefan Lanka showed recently in a controlled experiment where he showed this same process to happen without the mythical virus being present and thus this controlled experiment undermines the pseudoscience which is Virology. But getting to the point for lack of space: these doctors explain that when we get colds, the flu etc this is the organism naturally expunging out toxins from the organism, and along with this there is cell debris which is eat by exosomes, and it is these which are claimed to be ‘the enemy’. IE if seen on microcopes they have had little arrows pointing at them claiming they are the viruses. But this would like like seeing firemen at a burning house and blaming them for the fire. or seening maggots cleaning a cadaver and blaming them for the kill! it is rather the intelligence of nature. But LOTS and LOTS of money is to be made for the vaccination industry blaming viruses.
    So now I want to copmpare that process, as explained in Terrain Theory, with what the same medical model is calling mental illness/disorder. Like in general medicine the onus is on pushing drugs and injections which SUPPRESS symptoms. And isn’t this the same in the mental health field? Isn’t this what ‘ANTI’ ‘depressants’ ‘psychotics’ etc are all about. There is no understanding that as the body wishes for the expression of fluids etc, that in the psyche it is expression of emotions, feelings. Weren’t there sanctuaries provided for people to have space for that such as SOTERIA HOUSE, I-WARD, DIABASIS etc? And then big pharma and the State pulled the funding?
    When we understand the insanity that has happened and we are in, surely it them makes sense WHO feeling unhappy, and anxious are natural responses to a very insane culture. To understand just how insane, as well as what I explained, you need to be aware of the larger agenda, the so-called ‘Great Reset’ the powers that be want. Who have said they see the ‘pandemic’ as a great opportunity. They want to literally turn humans into ‘transhuman’ cyborgs totally controlled externally and internally. Listen to their fave advisor to dig their belief system. He is called Yuval Noah Harari.
    So in the spirit of Mad Pride we NEED the madness which sees their insanity so we do not fall prey to it!

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    • I’ve wondered for a long time whether psychiatry/psychology basically replaced witch hunting.

      Thank you for writing this, Justin. And there are quite a few people who have had spiritual awakenings misdiagnosed by the “mental health” workers, who do end up finding meaning and hope in their mind altering experience.

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    • Thanks for this interesting perspective! The French physician Philippe Pinel described madness as akin to fever, it was nature’s healing power. I’m not sure if that was always a good idea (or his idea that madness should always be allowed to “run its course”) but I think it’s an important and revealing metaphor.

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  3. Hi Justin – thanks for this. I am inclined to agree with l. e. cox, there have been many ancient paradigms – “demon possession” is played out today by White & Epston’s narrative therapy – they “externalise” the problem and then look for “unique outcomes”, ie. times when you didn’t succumb to the “devil” – and then build those (often unnoticed) responses until you are free. Madness-as-strategy can often be played out by viewing so-called depression as the time your ‘soul’ goes on the journey emulating the seasons – summer, things are fine; then autumn, when things die and it goes from wet to sunny many times a day; then winter, when I retreat into my heart’s cave to hibernate, & in the stillness of winter somethings crystallise; which is followed by spring, when there are lots of new flowers, many of which don’t make thru to summer. Even the ice age had its thaw. As a philosophy professor you’ll surely like Wittgenstein’s take on psychosis, which was partially inspired by Arthur Schopenhauer whom Witt. read as a young man – bringing back into balance the “soul” (the subjective self that “is the world”) and the objective self (see Sluga)….

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    • Thanks! I hadn’t read Wittgenstein’s take. I’ll have to look that up. I’m intrigued by this metaphor of depression as akin to soul-seasons. The image tempers the urge that people seem to have to immediately fight it, conquer it, eliminate it.

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  4. How very peculiar! I made a similar comment or two recently before catching this article right now. Thank you for your explorations of this debate.

    I chime with much of what you say. However, I wonder if even in this kind of topic the comments, each of them perhaps going to be brilliant and even genius, might weigh up the “logic” in what those old scholars said. To me the actual madness of our species is this over valuing of “cerebral cudos”.

    And because that “normalcy” seems the real madness to me then my own madness is a countering remedy.

    As I get better and better at being mad I find that I wince when I see a long academic dry screed of research. My mind has always swiftly binned the imposed “facts” that were stuffed by academia into it. I have nothing to regurgitate. I kick out “logic”. But I have not gone far enough and its faint echoes still drive me mad in that former way.

    I love my madness.
    But like most loves it is trying to finish me off.

    By this I mean I have two responses here. That madness being a remedy against the tyranny of the world’s “logic” is a form of blissful healing. But equally since madness is the very essence of the uncontrollableness of the “illogical” it can be as frightening and startling and every bit as tyranical as the world’s overbearing and vindictive “logic”.

    I love my madness.
    Yet it has me ill, ill, ill a lot of the time.
    And nobody likes feeling ill, not even the mad.

    So see it like this…madness is a liberation and it feels lovely for that. It becomes healing. Like as if it is a nature god who leads you away from tyrannical “logic” from the world. It helps you be an escapee. However a price is paid because you become hostage to a force far more powerful than even “logic” was. You then try to bargain and negotiate with that force. And you may use lots of “logic” to do so. But the force of madness does not listen to your “logic” any more than you listened to the world’s “logic” when you opted for your own healing. When that rubicon is crossed there is no going back. The force of madness has you. It decides when to wake you and when to nurse you and when to feed you and when to thump you with three hours of relentless hallucinations. No begging makes it stop.
    But curiously when that force becomes imposing and insistent and even pushy, it seems pushy towards you in the same way that the “logical” judges all over planet Earth are pushy.

    To this bullying you become one long wail.

    L E A V E ME A L O N E

    is the cry that comes out of your very heart.

    You howl it to your madness and you howl it to all the rational nitpicking punitive people.

    But your very howl IS MADNESS
    yet it is of a pure sort that saves you and saves you and saves you.

    So much so it becomes a cackle. A crone’s shriek of glee.

    And THIS is what you answer the world’s “logic” with. Rogue gibberish.

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    • “I love my madness.
      But like most loves it is trying to finish me off.”
      That’s powerful. Something can be a tool but still a destructive one.
      One of the metaphors I often hear nowadays is madness as a “dangerous gift”. Seems to capture a similar thought.

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  5. I don’t know. I kind a worry about incarceration as a strategy myself. I’ve been there, mad. A lot of it’s detractors, madness detractors, that is, haven’t been there. Intolerance I see as a problem. Suffering fools, I see, as the solution because, basically, no matter how hard you try, you’re not going to eliminate folly. Saying that, you can beat the authorities to the punch by getting in touch with your inner fool. Works for me anyway. He’s over there chatting with my inner sage right now.

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