Clinicians

Morgan helpfully begins and concludes his volume with the work of psychiatrists. The first is psychiatrist-turned-philosopher Karl Jaspers’ General Psychopathology (1911). Other early thinker-practitioners discussed include Eugen Bleuler, Carl Jung and Eugène Minkowski. Key later psychiatrists include R.D. Laing and David Cooper. Interestingly, if Morgan nourishes any hostility towards psychiatry, this pales by comparison with that experienced by Bleuler at the hands of German psychiatrists because of his sympathetic response to Sigmund Freud's ideas (Ch. 3) (here and below, chapter numbers refer to Continental Philosophy of Psychiatry).^{Reference Morgan1}

Morgan is a philosopher with a doctorate on the theme ‘Life does not live’, the epigraph to Frankfurt critical theorist T.W. Adorno's (1903–1969) glum aphoristic masterpiece Minima Moralia.^{Reference Adorno2} In the light of such preparation, it is not surprising that he has a lot to say about theories that view schizophrenia as alienation and withdrawal from life itself, a disorder of ‘pre-reflective experience [ … ] such as lived time, vitality, embodied presence, minimal self (ipseity) and an immersed presence in the world’ (p. 67).^{Reference Morgan1} This discourse, though insufficiently familiar to many psychiatrists today, remains of relevance to our contemporary phenomenological psychopathology;^{Reference Stanghellini, Broome, Raballo, Fernandez, Fusar-Poli and Rosfort3} and not only in the work of Josef Parnas^{Reference Parnas, Møller, Kircher, Thalbitzer, Jansson and Handest4} (https://easenet.dk/) and Louis Sass.^{Reference Sass5} No failure here! The discussion is illuminating, and it is interesting to read how ‘Freud: the reluctant philosopher’^{Reference Tauber6} stands shoulder to shoulder with others more committed to this discipline when discussing paranoid psychosis (Ch. 4).

A word of caution. Philosophical formation is no guarantee of clinical success. Of interest is the case of Ellen West, a patient treated by renowned Swiss psychiatrist Ludwig Binswanger (1881–1966) (Ch. 8). It caused a storm of controversy after he published regarding his anguished decision to allow her to leave his clinic at a time when his ‘existential analysis’ had led him to conclude that suicide was inevitable, which is indeed what happened soon after her discharge from Bellevue Hospital in Kreuzlingen. As Morgan points out, today we would see that she had been crushed repeatedly as a victim of patriarchal misogynistic oppression, something not addressed by Binswanger. My reading of Morgan's retelling also suggests that West's was a reasonably straightforward case of treatable major depression diagnosable on grounds of descriptive psychopathology.^{Reference Oyebode7} This, of course, does not entail dismissal of ‘existential analysis’, only recognition of its limitations and the need to complement it by other means. Such complementation, I would suggest, may not simply consist of psychiatric treatments [such] as medication and psychotherapy, but include socially critical political commitments against patriarchy and misogyny, racism, etc. Because psychiatrists have often been followers rather than leaders in such matters,^{Reference Rands, Ikkos and Bouras8–Reference Joseph, Bhui, Ikkos and Bouras10} I turn now to some innovative thinkers discussed by Morgan.

Thinkers

A look at the index shows that Michel Foucault's (1926–1984) name comes second only to Freud's in number of references, with Martin Heidegger's third. A welcome strength of the volume is that we can trace some of the evolution in his thinking across parts II–VI. Part IV, ‘A certain madness must watch over thinking’, is about his (Ch. 13 and Ch. 14) and psychiatrist and psychoanalyst Jacques Lacan's (1901–1981) (Ch. 15) theories of madness. Morgan explains in detail how for Lacan ‘Madness, however disavowed, lies at the heart of reason’ (p. 250),^{Reference Morgan1} a credible proposition to my mind, even if others may differ. It is echoed in the important Foucault–Jacques Derrida (1930–2004) philosophical debate on madness.

Morgan explores the Foucault–Derrida debate. He warns that it ‘consists of a series of texts that concern a wide array of philosophical questions in an often confused and confusing manner. The term “debate” is a misnomer as the first response to Derrida's critique was a lack of contact between the two philosophers for ten years following Derrida's initial lecture’ (p. 258). The key issue was Foucault's formulation and use of the philosophically abstract concepts of reason, unreason and madness, particularly his insistence in early editions of his History of Madness ^{Reference Foucault11} that reason silenced unreason and madness during the Enlightenment. Much of the debate centred around Descartes’ Discourse on Method ^{Reference Descartes, Cottingham, Stoothoff and Murdoch12} as the harbinger of the Enlightenment, including the great rationalist's reference to madness in that text. Derrida suggested that there is ‘a paranoiac grandiosity’ (p. 264)^{Reference Morgan1} in Descartes’ ‘solipsistic statement’ that ‘I think, therefore I am’.

‘The [Enlightenment's] moment of philosophical certainty and the grounding for a philosophical system do not rest upon the exclusion of madness but rather on a strange madness within philosophy’ comments Morgan (p. 264), arguing that Foucault and Derrida came to echo Lacan in that ‘ultimately [madness itself] cannot be spoken about or speak, but that it nevertheless registers; it haunts reason and watches over reason from a distance’ (p. 250). Among the consequences that followed for Foucault, writes Morgan, one was to allow explicitly for the investigation of mental illness empirically in our contemporary scientific way, quite apart from any abstract speculations about ‘reason’ and ‘unreason’. Another was to shift his focus from the relation between reason, unreason and madness to that between transgression and madness, hence the title of Ch. 14 and subtitle of the book The Lure of Madness. Morgan concludes ‘At his best, Foucault traces the negative space of madness as both limit and critique of a certain fate of Western reason and responds to the suffering of madness. At his worst, he outlines a concept of madness as unreason that lies in an empty transgression of reason’ (p. 281). What interested Foucault consistently, however, in his mature writing was how power shapes institutions, thinking and practices across history, including psychiatry's history. I move on now therefore to two psychiatrist-activists who took power head on.

Activists

Frantz Fanon (1925–1961) ‘is the most complete example of the philosopher-psychiatrist’ avers Morgan (p. 224).^{Reference Morgan1} In his thesis on Friedrich's ataxia, where he examined issues of freedom in neurological illness, Fanon combined phenomenological, gestalt and Lacanian approaches. He argued that ‘There is a pathology in the heart of freedom, in that the more one asserts an empty autonomous freedom, the more this freedom dissolves into anonymity’ (p. 227). The value of Fanon's work according to Morgan arises from the fact that it ‘begins with an understanding that the “mad person” is one who is “foreign to society” and therefore all psychiatric work is an attempt at disalienation, an effort to return the person to a place in society [ … ] For Fanon, the attempt at disalienation that led him to psychiatry as a profession demands radical questioning of wider pathologies in society [ … ] Fanon returns to the central phenomenological question but with a critical lens’ (p. 224). A turning point for him was when he was travelling by train and a child turned to its mother and said ‘Look, a Negro!’. Fanon summarised ‘I came into the world imbued with the desire to attain to the source of the world and then I found that I was an object in the midst of other objects’ (quoted by Morgan, p. 231). His first major work, Black Skin, White Masks, a pioneering treatise on what has become the study of pathologies of recognition, is a ‘radical melange of phenomenology, psychoanalysis, literary criticism and political rhetoric’ (p. 226). Importantly, ‘Rather than madness as a breakthrough, Fanon consistently views it as a lack of freedom and that the psychiatrist's role is to try and restore a sense of agency and freedom to the person’ (p. 227).

Issues of mental health and illness and their relation to freedom have continued to be discussed since.^{Reference Fulford, Thornton and Graham13} What Morgan's account suggests is that for Fanon freedom is not an abstraction, but an experience rooted in one's body and circumstances and it always needs to be examined with explicit reference to their concreteness. Furthermore, substantive freedom emerges from lively engagements with these, not their empty transgression. Consistent with this, Morgan places Fanon's ideas and practice in the context of his biography and thus helps deepen understanding of their nature and significance.^{Reference Macey14} Fanon was born in 1925 in Fort-de-France, in the wretched conditions of French colonial Martinique in the Caribbean. In 1944, he joined General Charles de Gaulle's (1890–1970) ‘Free French’ and fought in Morocco, Algeria and, finally, in France, where he was appalled by the racism with which the African Senegalese were treated, even worse than the Caribbeans. Following the war he trained in medicine in Lyon and psychiatry in the Saint-Alban hospital, which had previously distinguished itself by sheltering resistance fighters and by protecting its patients from starvation in ways that other French mental hospitals had not during General Pétain's pro-Nazi Régime de Vichy (1940–1944). By 1952–1953, when he joined the staff, it had also pioneered the ‘institutional psychotherapy’ approach to treatment, a distinctly French approach to group and community therapy influenced by Lacan and Marxism. He took his ideas to Algeria, where he first challenged colonial psychiatrists’ racist theories of ‘the North African syndrome’ and later joined the Algerian Front de Libération Nationale (FLN), endorsing its violent insurrection against France's brutal colonial occupation. In Algeria he sheltered local insurgents in his hospital in Blida and then, in exile in Tunis, he combined anti-imperialist political leadership with psychiatric practice with patients traumatised by the French reaction.

A word of caution about Fanon too. He is clearly a kind of hero for Alastair Morgan and his reputation has been further enhanced in our contemporary context of ‘Black lives matter’. It is a tribute therefore to the author's intellectual and ethical integrity that he does not shy away from referring to Fanon's and his Saint-Alban colleagues’ engagement in the ghastly and aptly named ‘annihilation therapy’. This combined electroconvulsive therapy, insulin therapy and sleep therapy in the context of the institutional psychotherapy in this hospital. Morgan quotes (p. 230) from Fanon's and François Tosquelles’ paper ‘On some cases treated with the Bini method’: ‘The point here is to situate annihilation therapy through repeated shocks within an institutional therapeutic performance’. Morgan continues incredulously: ‘The point of the shock treatment was not an end in itself but to try and create a kind of “new birth” in the patient, although quite what was left after Fanon and François Tosquelles had finished beggars belief, as they describe the following course of treatment with one patient: “Five days of annihilation treatment, she had seventeen electroshocks … forty sessions of insulin shock therapy”’ (p. 230). Fanon thus emerges as a somewhat ambiguous figure rather than an undisputed hero. Also, his endorsement of political violence has divided opinion. Some demure from it, others have criticised him heavily, yet others, including existentialist philosopher Jean-Paul Sartre, joined him in advocacy for the FLN.

Another psychiatrist noted by Morgan who made direct use of experiences of oppression and war to challenge psychiatric institutions and society was Franco Basaglia (1924–1980). He had taken part in resistance to Benito Mussolini's (1883–1945) fascist dictatorship (1922–1943) and had been imprisoned in Italy.^{Reference Foot15,Reference Burns and Foot16} An existential phenomenological psychiatrist influenced by Sartre, he abandoned his academic post in Padua after the war to work in Italy's primitive and despised asylum system in Gorizia and Trieste on the north-east coast of the Adriatic Sea. Noting the similarities between mental hospitals and prisons, even the smells, he set out to close the asylums both in the region and nationally. His ‘Psichiatria Democrática’ movement was radically political and succeeded in the Italian parliament with Law 180, which mandated the closure of all mental hospitals from 1978.