Is Madness an Evolved Signal? Justin Garson on Strategy Versus Dysfunction

Justin Garson is a Professor of Philosophy at Hunter College and The Graduate Center, City University of New York, and a contributor for Psychology Today and Aeon. He writes on the philosophy of madness, the evolution of the mind and purpose in nature. His most recent book is Madness: A Philosophical Exploration, published by Oxford University Press in 2022. He is also the author of the forthcoming The Madness Pill: The Quest to Create Insanity and One Doctor’s Discovery that Transformed Psychiatry, which will be published by St. Martin’s Press.

In this interview, Justin joins us to talk about the ways in which society has attempted to explain or categorize madness over the years. We also discuss the value of looking at madness, not as disease or defect, but as a designed feature.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

James Moore: Justin, welcome. Thank you so much for joining me today for the Mad in America podcast. I’m delighted to get to chat with you about your work and your latest book.

Justin Garson: Thank you so much, James. I’m really happy to be here.

Moore: To begin with, I’d like to ask a little bit about you. So you’re a Professor of Philosophy at Hunter College in New York and you have a particular interest in studying madness, the evolution of mind and purpose in nature. You’re also an author, and you’ve written on topics such as aging, genetics, mental representation, biological functions, mechanisms in science, and the concept of information in neuroscience. Your work is often at the intersection of philosophy, madness, and biological function. So what was it that led to your interest in these subjects?

Garson: My interest is in psychiatry and madness is lifelong. A few months after I was born, my dad was diagnosed with paranoid schizophrenia. He was working under Richard Nixon at that time, and I think that that had something to do with it. Nixon was famous for surveilling his staff, and I think that my dad was surveilled at one point. I think that the stress of that triggered a series of psychotic episodes and he was hospitalized. He was able to return to work, but about 10 years later he had similar episodes that really made it impossible for him to continue working.

And so I spent a lot of my teenage years visiting him in various mental hospitals and getting a very clear glimpse of the toll of this cycle of hospitalization, labelling and drugging. Then eventually getting out and getting re-hospitalized, labelled, drugged, and so on. Then at 16, I was hospitalized for depression for about six weeks. I got first-hand experience of what it’s like to not be able to walk off the premises of a hospital because a doctor doesn’t think that you’re fit to leave. I was also put on Prozac. This was the late ’80s, so at that time it was still considered this “wonder drug” that was going to reverse the “chemical imbalance” that causes depression. So by the time I was 16, I’d probably seen more of the inner workings of psychiatry than anyone really should.

Around 2000, I was a graduate student in philosophy, and I wanted to explore some of these questions from a more philosophical and historical point of view. One of the big philosophical questions at that time was what they called the “demarcation problem” namely, how do you distinguish madness or mental illness from any other kind of socially disvalued behavior? So why do we call schizophrenia a mental disorder, but not believing in conspiracy theories? Why do we consider depression a mental disorder but not jealousy?

At that time, and I suppose this is still true if you ask a lot of psychiatrists how they decide whether something is a mental disorder, a lot of them would say, “In order for something to be a mental disorder like schizophrenia or depression, there has to be something objectively not working right inside that person. There has to be something in their mind or their brain that’s just not functioning the way that it’s supposed to. That’s what distinguishes depression from just ordinary jealousy or grief.”

But then of course, if you’re a philosopher you’re going to have one more question, namely, how do you decide what’s functional and what’s dysfunctional? Who gets to decide whose brain or mind is functioning well and whose brain or mind is functioning poorly? And are you sure that’s not just a kind of concealed way of introducing these value judgments? And usually, those kinds of questions were met with complete silence.

So I started getting very interested as a philosopher in thinking about what are biological dysfunctions and what are functions. When a biologist says the function of zebra stripes is camouflage, what do they mean by function and dysfunction? Let’s figure out what that means on a biological level, and then think about how it might apply to psychiatry.

From there, I got very interested in conceptual problems of biology. So I got interested in function. I got interested in the concept of information in neuroscience. I got interested in the concept of aging and whether evolution can help us understand the human mind. So it’s only in the last several years that I’ve finally been able to work my way back to my primary interest, which is paradigms in psychiatry and how we think about madness as a society.

Moore: Just before we come on to talk about your book, I’m interested in your choice of the term madness rather than mental illness or disorder or mental health or whatever it might be. You’ve written that using the term madness is your preference. So I wondered if we could talk about that a little bit.

Garson: As you know, the term “madness” has been or is in the process of being re-appropriated or reclaimed and in many circles, it’s no longer considered a derogatory term. So we can talk about the Mad Pride movement for example. It connotes something like difference, perhaps surprising difference, perhaps sometimes harmful kinds of differences, perhaps sometimes insightful kinds of differences.

Secondly, it seems to me when you describe something as a mental disorder or a mental illness, you’re already presupposing that this phenomenon falls under the authority of medicine, that it’s the doctor’s job to deal with. That’s, of course, an assumption that I want to put into question. So there’s something, to me, which would be very wrong about using a term like mental illness or mental disorder to help explore the philosophy and history of psychiatry when that term just reinforces this assumption that I want to challenge.

Moore: I’d like to go on to talk about your 2022 book entitled, Madness: A Philosophical Exploration. It’s a fascinating journey through the many ways in which society has attempted to explain or categorize madness over the years. As I mentioned to you before, it’s one of those books that I found myself reading and after every four or five pages or so, I’d have to put it down and have a good think about what I had just read. That to me is the sign of quite a meaningful book.

So, for example, in the book you recount that the philosopher Immanuel Kant begins his taxonomy of madness in his 1764 “Essay on The Maladies of the Head.” He says, “There are three faculties of the human mind: experience, judgment and reason. Consequently, there are three, and exactly three, basic forms of madness, and each form corresponds to a breakdown in one of the three faculties.”

Then if we contrast that with modern times, we’re now on to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which I believe has something like 157 listed disorders. But despite this explosion of diagnoses, the story doesn’t appear to be one of settled science. So I wonder, in your research, what did you come to think about the way in which we’ve pursued a definitive classification of mental suffering?

Garson: Let’s maybe go back to a big-picture perspective. So the purpose of the book generally was to really rewrite the history of madness. And often when historians write about the history of psychiatry they write about it in terms of a clash or confrontation between two views, a biological brain-based point of view and a psychological mind-based point of view, which is fine and there’s a lot of truth in that. But I wanted to use a slightly different lens. I wanted to look at the history of psychiatry as a clash between two paradigms which I call madness-as-dysfunction and madness-as-strategy.

The basic idea behind madness-as-dysfunction is this notion that when somebody is mad, it’s because something inside of them isn’t working the way that it’s supposed to. Something in your mind or your brain just isn’t working right. You’re looking at the person kind of like a broken machine, and your job as a doctor is to figure out how to fix that machine.

There might be some benefits to it, but in some ways, what I’m calling madness-as-dysfunction is very harmful. When I decide to look at your words, actions and feelings as the byproduct of a broken mechanism, that robs you of a certain level of personhood or agency.

The other paradigm is what I call madness-as-strategy, where you’re willing to see in madness something like a purpose or a function or an adaptation. And I can come back to that later a bit more about what I mean by madness-as-strategy.

But to answer your question, the view that I’m calling madness-as-dysfunction is not new at all. It’s actually very old. As you know from the book, it goes back to the Hippocratic doctors. If you look at the book On the Sacred Disease, written probably around 400 B.C., the view that the author lays out very clearly there is that all the different forms of madness just stem from oxygen deprivation to different parts of the brain. And it’s interesting that you mentioned classification because once you have this basic idea that madness represents a disease or dysfunction, it becomes extremely tempting to want to classify the different forms of madness in terms of the different ways that the mind can fail to work the way it’s supposed to work. In the same way that you might want a listing of all the different ways that an automobile might fail to work the way that it’s supposed to work.

You see this, as you mentioned, in the 18th century philosopher Immanuel Kant, where he says there are only three forms of madness because there are these three different faculties of the human mind, and so there are only three different ways that the mind can break down. You see this in the DSM, you see this in the RDoC (Research Domain Criteria). As I see it, they’re all just versions of the same project, listing all the ways that the mind can break. Of course, things are different today, because unlike Kant or the Hippocratics, we have many different ways that the mind can break down and apparently it’s quite a lucrative business.

Moore: I’d like to ask more about madness-as-dysfunction versus madness-as-strategy. In reading the book, you see this gradual change and the creeping medicalization to perhaps put psychiatry in charge when it’s a dysfunction view. But it struck me that if madness is seen as a dysfunction it immediately puts the medical professional in charge. They know the diagnosis, they know the outlook or prognosis. But if you look at it as madness-as-a-strategy, then surely the person experiencing or having developed that strategy to avoid a painful reality is the one in charge. It made me wonder if there are important reasons to think about madness outside of a medical context, and if so, are there benefits to thinking about madness in this way?

Garson: That’s a great point. I do suspect that there is a very deep connection between what I’m calling madness-as-dysfunction and psychiatry as such. So sometimes I talk to psychiatrists who say, “Look, you’re describing this one particular point of view, but we have a lot of different points of view. Sometimes we use what you’re calling madness-as-dysfunction, and sometimes we use madness-as-strategy and we take a very individualistic and pluralistic approach.”

But it does seem to me that to the extent that we think of psychiatry as a branch of medicine, it has to be wedded at a very deep level to a dysfunction or a disease-centred view of madness. Otherwise, why would it fall under the authority of medicine? If you didn’t think that madness was something like a disease or something going wrong inside of you, then it’s not clear why that would be a medical problem at all.

So that’s why I do think that even though there are some psychiatrists who take very progressive, and interesting and different points of view on madness, I do think that the profession as a whole is wedded to a certain dysfunction-centred point of view.

So I guess the core shift that I would like to see is a shift from pathology to purpose, or a shift from madness-as-dysfunction to madness-as-strategy. And it’s almost impossible to describe madness-as-strategy in the abstract. As you know, I have a blog with Psychology Today that I use to explore what I see as a lot of different research programs in mental health that exemplify what I’m calling madness-as-strategy.

If any of the listeners wanted to find that, you can go to my website and you’ll see links to all the posts there. There I talk about depression, I talk about some of the so-called personality disorders. I talk about delusions, voice hearing, some of the conditions that fall under the neurodiversity banner and what it would really mean to shift from a pathology to a purpose point of view.

Just to give you one example of what I’m talking about, we can take depression. As you know, for decades we’ve been searching for this hypothetical brain abnormality underlying depression. That project has not panned out very well, as far as I’m aware. But there’s a newer paradigm which has been inspired by some of the evolutionary thinkers. And in this paradigm, depression is far from being a brain disease, it’s something like your mind’s evolved signal. It’s something like a designed signal that your brain is giving you that something in your life needs to change and needs more attention.

So in a way, the evolutionary theorists look at depression in the exact same way that we look at pain. So suppose you stub your toe or burn your hand, you feel this excruciating pain. Feeling the pain, that’s not a disease, a disorder, or a dysfunction. That means everything inside of you is working exactly the way that it’s supposed to. The pain is your body’s natural signal to get yourself away from the source of danger. And so a lot of the evolutionary thinkers see depression and anxiety in the same way, as something like your brain’s functional signal that there’s something in your environment that needs more attention. So that would be one example of shifting from a pathology to a purpose viewpoint on depression.

Now, if that’s true that would have profound implications for research, for treatment and stigma. So think about treatment. If I’m treating somebody for depression, the first question isn’t going to be, okay, let’s look for some hypothetical chemical imbalance that’s creating your depression. The first question is going to be, okay, what in your life might this be a response to, it’s probably not something really obvious but something real that needs more attention.

I think it would also change our readiness to medicate. I’m not saying that medication has no place at all in depression, but if we do think of depression on the model of a functional signal then the first step is probably not going to be to bombard it with drugs. The first step is going to be looking at what in your life it might be a response to.

And then finally, I think it has deep implications for stigma. So there’s a researcher that I’ve been working with, a psychologist at the University of Michigan named Hans Schroder, and he studies the psychological impact of different ways of framing depression. So he’ll get together a huge number of volunteers who have had experience with depression. To half of them, he’ll give a dysfunction-centered message. He’ll say something like, “We now know that depression stems from some kind of a chemical imbalance in your brain and it can be treated in one of various ways.”

To group two, he’ll say, “We now know that depression is something like pain. It’s like your mind’s functional signal that something in your life needs more attention.” And then he looks at the impact that these different messages have on people. And what he’s found is that people who are exposed to this function framing tend to be more optimistic about treatment. They tend to think, okay, this is something that I can get a hold of. They tend to feel that their depression has some important insights to offer them, and they tend to feel less stigma about their depression, they tend to feel more inclined to talk with other people about their depression. So that’s a lot to say, but I think that there are a lot of far-ranging implications of thinking of what we call madness in terms of purpose.

Moore: It’s fascinating to think about how much shame it removes for people when they might think for themselves, “I’m in a perfectly understandable place, it’s a perfectly understandable reaction to some horrible circumstances that I’ve been in,” rather than give them a message that there’s a mechanism that we can’t really explain in your brain, but we’re going to chuck chemicals at it and hope it somehow resolves itself. I was really heartened to read that if you encourage people to think of this understandable reaction then it tends to be quite positive for them and their experience of the whole situation changes.

Garson: I really do think that over the last decade, psychologists are discovering just how disempowering and stigmatizing these biomedical framings are. Which is a surprise because in the ’80s I remember very clearly when they would say, “Once we start thinking of mental illness on the model of diseases, once we get everybody to think that depression is kind of like diabetes or schizophrenia is kind of like cancer then we’re going to have this golden age where suddenly people will not feel stigmatized and will not feel at fault and they’ll be able to talk about it.” I think it’s really the last decade we’re seeing that, okay these messages can be extremely disempowering and stigmatizing in perhaps a different way than we anticipated.

Moore: Justin, what are your thoughts on how it is that the medical model has become so deeply entrenched in our society and our culture? It’s interesting, isn’t it, if you talk with friends and you talk about people suffering mental distress, and you mention poverty, inequality and injustice or whatever else it might be, then they kind of get that those things can put people in a very difficult place. But if you talk about mental illness in that regard, then the conversation very quickly becomes scientific and medicalized and holding psychiatrists as the experts. So this biomedical narrative has really taken hold, hasn’t it?

Garson: That’s such a huge question. I think there are so many factors. As you know, in my view, there’s this dysfunction-centered view that’s very old and we see it repeatedly throughout history, but I think you’re absolutely right. Something happened around the 1970s and 1980s, and this medical dysfunction-centered view just became entrenched in our collective consciousness. And the way that we think and talk about mental illness to the point where people often get offended if you suggest that what we call madness or mental illness is anything other than a medical problem. And I think there are so many reasons why that change took place.

I’m actually writing a book about that very topic right now that’ll be coming out in a couple of years with St. Martin’s Press, exploring from the point of view of one particular psychiatrist named Solomon Snyder. I’m kind of looking at his life and exploring how this medical point of view took hold partly through his actions and advocacy.

Snyder was really the innovator of this dopamine hypothesis of schizophrenia in the 1970s. He did a lot of important work. He discovered the brain’s dopamine receptor. He showed that the first-generation antipsychotic drugs primarily seemed to work by blocking up dopamine receptors. And on the basis of that, he formulated what seemed like a very simple and appealing idea, namely schizophrenia just comes from the dysregulation of your dopamine neurons.

It’s thanks to that dopamine hypothesis that the floodgates for this biomedical perspective really opened. There had been a lot of people obviously throughout the century who had endorsed a biomedical disease-centered perspective in contrast to say psychoanalysts or people with a more sociological orientation. But I think that the dopamine hypothesis and then later the serotonin hypothesis gave ammunition to this biomedical point of view. And they were able to say, look this is no longer a speculation; this is basic science that we’re dealing with. But there are a lot of factors I think that influenced that.

Moore: And of course, it was an open door then for the pharmaceutical industry, wasn’t it, with their massive marketing dollars. Wasn’t the slogan that accompanied the marketing of Prozac “Better than well”? So they suddenly saw themselves as able to chemically manipulate people’s behavior. Not only were they treating a disease, but they could apparently improve people’s lives. And a lot of the marketing went along with that.

Garson: Right. Once you have what seems to be a scientifically vindicated idea that these major mental disorders can now be explained in terms of neurotransmitter abnormalities in the brain, that is an open field, obviously for pharmaceutical companies to come along and say, “Hey, guess what, we have exactly the drug that’s going to reverse that chemical imbalance.”

One person I really have come to respect quite a lot is Joanna Moncrieff. I think that she sees something that a lot of historians miss, which is that one of the factors that led to the entrenchment of the biomedical view was not the availability of these drugs; most of the drugs that are on the market today are versions of stuff that’s been around since the 1950s. It was this changed philosophical and conceptual understanding of what these drugs actually do.

The idea became that drugs like chlorpromazine, and drugs like Prozac, they don’t work just by helping you to dampen your emotions. They’re not just tranquilizers. They are specific, targeting underlying chemical abnormalities. And I think she’s right that medical psychiatry and the pharmaceutical companies needed a vision like that. It wasn’t enough to say, “Look, these drugs seem to help some folks maybe they’ll help you too.” We needed to have this idea that these drugs reverse a chemical imbalance. I do think that’s why she’s gotten so much flack. She gets criticized so heavily by psychiatrists because by questioning that assumption, by questioning the idea that these drugs work by reversing chemical abnormalities in the brain, you’re unravelling the whole basis of this solidification of medical psychiatry in the ’80s. It’s a very dangerous thing to say.

Moore: It’s removing the foundation stone from the story of mental illness and drugs to fix chemical imbalances. I’ve spoken with many people for whom the effects of the drugs often cause more problems than the issue that you’re dealing with in the first place.

Garson: I don’t doubt that they help some people but if I’m going to take these medications I’d rather just know, look we don’t really know why they work. They seem to help some folks maybe they’ll help you. And then I’ll take my chances. But certainly, it was true for me in the late 1980s and I assume it’s still true for a lot of people now that I wouldn’t have taken these drugs if I didn’t actually believe that they weren’t reversing some kind of a chemical imbalance. That was the basic presumption that I had when I took these drugs. I didn’t just want to take drugs that would somehow impact my mind in such a way to make me feel a bit better.

Moore: While reading your book and other books that I’ve read around this subject it’s plain that there’s a huge amount of fantastic academic work, looking at is there benefit in thinking more widely about how we conceptualize mental suffering or distress or madness. And yet, of course, when you get out into the real world, then the whole mental health conversation is still very medicalized. It’s still really the purview of doctors and psychiatrists.

I think you have said that people have the right to be exposed to different frameworks for making sense of their suffering, as long as those frameworks are scientifically credible. So my question is how do we start to cut through this dominance of the medical model narrative, do you think?

Garson: That’s a great question. How do we start to change things? Let me just say a word about this notion of the medical model itself, because I often run into this kind of objection. I’ll talk to folks who say, “Look, psychiatry isn’t really using a medical model anymore, we’ve moved past that. We now have a biopsychosocial model, which is very pluralistic and very tailored to the needs of the individual.” And to me, I see all this talk of the biopsychosocial model as the proverbial wolf in sheep’s clothing.

To me, the whole question is are you seeing madness-as-a-dysfunction? Are you seeing it in terms of something inside the person not working the way that it’s supposed to? Seeing madness-as-a-dysfunction is perfectly compatible with taking a biopsychosocial approach. I mean, you can take a biopsychosocial approach to cancer. You can take a biopsychosocial approach to diabetes. You should take a biopsychosocial approach to these various diseases. But that doesn’t mean that you’ve moved at all away from a disease or a dysfunction mentality. So I do see that the biopsychosocial model is really just the medical model in disguise. It’s maybe a more philosophically sophisticated version of the medical model.

On the topic of changing paradigms, to some extent, I’m skeptical that psychiatrists will be the ones to lead the way in this movement. And it’s not necessarily just because they have so much at stake. But I think part of the extensive medical training that they get is just reinforcing the idea that they are actually dealing with diseases or disorders and they need to fix them.

As I said, there are a lot of psychiatrists who do not fit that mould, who are doing great, groundbreaking, important work trying to move away from dysfunction-centered framings. I respect them profoundly. But I do think that as long as we see psychiatry as a branch of medicine, as an institution, psychiatry is going to remain wedded to these dysfunction-centered models.

So I think it falls on each of us to take as many opportunities as we can simply to promote new models and promote alternative models. I like to think of what I’m doing as trying to kind of clog up the infosphere with different models of madness. And I’ve been fortunate in some ways because I’ve had some platforms that I can do that with, like Aeon, Mad in America and Psychology Today. The book I mentioned that’s going to be coming out with St. Martin’s Press. But I do think at this point, it really is about finding creative ways of just getting these alternative framings out there to the public and to the people who need to hear them the most.

Moore: Thank you, that’s so important. And then perhaps if we look towards the future a little bit. If we were to move away from a medicalized view of madness, and if we were to embrace the idea that madness has purpose and we can learn from it, how could we or how should we organize ourselves to best fit people struggling? Are there lessons from history that can be useful? Or do you think we haven’t really yet found a way forward?

Garson: That’s another huge question. I can’t really say what mental health will look like in the future. Obviously, it’s going to look very different for different people who are experiencing distress or even just in extreme states of consciousness. I do think there are a lot of non-pathologizing approaches to mental health. I suppose that the most exciting and promising of these are projects that are led by mad people, by service users, by ex-patients, by people who have been diagnosed as having serious mental illnesses. So of course, you have projects like the Hearing Voices Network or the Open Dialogue Movement or Soteria Houses. From what I understand, these put the emphasis on peer support and on exploring alternative non-pathologizing framings of these extreme experiences.

As I’ve said, and I thank you for pointing out, I don’t entirely reject medical framings of certain kinds of distressing or extreme experiences, but I do believe firmly that everybody has the right to be exposed to different models, different frameworks for making sense of their experiences, so long as these are scientifically credible and not just made up. So in some ways, I do feel very hopeful about the future.

Moore: Your whole point is that if people see madness-as-a-strategy, that puts those people in the driving seat to be part of their own recovery if indeed recovery is what they need or what they are looking for. But if it remains in the medical domain then they’re kind of always relegated to a second role only of listening to a professional or an expert when probably they are the expert in their own experience.

Garson: I do think what I call madness-as-strategy is just one alternative paradigm for getting away from this dysfunction. I’ll just call it a dysfunction-centered model, because when I talk about the medical model, people say, “Oh, there is no medical model” or “We’ve moved past the medical model.” But yes, as I see it, madness-as-strategy is one promising alternative to the dysfunction-centered model, but I do not doubt that there are other alternatives. I like the way you put it. It’s about putting the person in the driver’s seat and giving them tools to think about and make sense of and possibly change the way that they’re experiencing the world in a way that doesn’t relegate it to some kind of a byproduct of a disease process.

Again, there are some people for whom that might be a useful and valid way of seeing things. And I don’t want to rob anybody of something that’s going to be a useful and valuable tool, but it certainly doesn’t deserve the dominance that it’s come to acquire.

Moore: Thank you, Justin. It’s been fascinating to talk with you today. Your book was mind-expanding in the best possible way. To get an appreciation of the way that we’ve thought differently about madness over all the years and the fact that it isn’t sorted even now was so interesting to read. Thank you for spending some time with us today.

Garson: Thank you, James. I do appreciate your taking the time to come up with these really just interesting and insightful questions. And I really appreciated our conversation.

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