Whereof One Cannot Speak: Richard Gipps on Madness and Rational Understanding

This interview is part of a series featuring in-depth conversations intended to foster a re-examination of philosophical and scientific debates in the psy-sciences. It is a continuation of my prior series, “Conversations in Critical Psychiatry,” but with a broader focus and a new orientation.

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Richard Gipps, PhD, is a Philosopher and Clinical Psychologist with a private psychotherapy practice in Oxford, UK. Here he’s also a Senior Research Fellow at Blackfriars Hall and Associate of the Faculty of Philosophy. He co-edited the Oxford Handbook of Philosophy and Psychiatry (2015) and Oxford Handbook of Philosophy and Psychoanalysis (2019). His philosophical monograph On Madness: Understanding the Psychotic Mind was published by Bloomsbury in 2022. His other interests include phenomenological psychopathology; the philosophy of the later Wittgenstein; an ethics of humane recognition and its place in psychotherapy; and the life of the soul and the nature of loneliness, dignity, and lovability.

This interview is focused on the philosophical themes from his book On Madness.

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Aftab: You take an ‘apophatic’ approach to psychopathology in your book and make the claim that “we can best understand the depth and character of the psychotic subject’s disturbance by understanding why some of the things we most want to say of her cannot strictly speaking be said. The fact is that various of our epistemic and psychological predicates presuppose, for their meaningful application, the sanity of their subject.” (p 3) Can you elaborate on what this means and also on the central thesis of the book?

Gipps: ‘Apophatic’ is a term I borrow from theology and extrapolate to the psychopathological context. Theologians speak of both positive (cataphatic) and negative (apophatic) approaches to God. Positive approaches attempt to understand the Divine by articulating His true properties (He is supremely loving, just, powerful, etc.). Apophatic approaches try to honor the theological intuition that something is inadequate, perhaps even idolatrous, in such predications and attempts at understanding. Such talk can be meaningfully used to characterize this or that being within the universe, but might it not fall apart when used to attempt to describe that which transcends yet bodies forth into it, that in which we live and move and have our being, the ‘ground of being’, Love or Being itself? So despite our best intentions, the negative theologian says, we inevitably fail to adequately characterize that of which we’re talking. Our descriptive language, after all, is designed for the purpose of characterizing the properties of beings. The apophatic thought, then, is that we do better justice to God, we better understand his transcendent nature, precisely when we see why even our most strenuous attempts must inevitably fail. It is then in our experience of the breaking apart of our attempts to comprehend Him, along with an understanding of why they inevitably fail, that we encounter Him more truly in all His terrible majesty.

Let’s turn now to psychopathology. Our whole everyday approach to one another is one which tries to grasp what others are doing (Why is Jones waving his arm? He’s hailing a cab) and what they’re getting at with their words (when Smith said he’s gonna take them out, he meant for a nice meal, not assassination). Ordinarily, this is just automatic, and baked right into our perceptual encounters themselves: I see straightaway that Jones is hailing a cab - after all, I encounter him on the sidewalk facing the road, I’m familiar with the custom of cab-hailing, etc. I don’t typically first of all see him move his arm and then think to myself, ‘What’s Jones doing that for?’! Sometimes, however, we’re puzzled by what someone says or does. Could the Australian Morning Bulletin reporter really have meant to write that “more than 30,000 pigs were floating down the Dawson river”? That’s more pigs than were ever in Baralaba in the first place! Well, it turns out we can retrieve sense by locating a mistake in the reporting: what piggery owner Sid Everingham actually said was that more than “30 sows and pigs” were floating down the Dawson. Now, when we see the person suffering acute psychosis doing and saying peculiar things, it can be equally tempting to attempt to retrieve rational intelligibility in the same manner. Hung up on the (‘cataphatic’) thought that the way to do human justice to one another is to accurately locate what’s said and done within the order of expressive intelligibility, we try to make those peculiar acts and utterances which evince psychosis into expressions of unexpected meanings or of mistaken judgments and thereby bring the psychotic subject back within the rational fold. What I suggest in On Madness, however, is that this can falsify psychotic thought and experience, making it out to be far more business-as-usual than is warranted. An apophatic approach, by contrast, can help us honor the psychotic subject’s experience as it is, without distorting it through our temptation to make it make rational sense, without deflecting from the dread that comes up within us when we resist that temptation, a dread which itself aptly registers the dread and terror which attend the psychotic experience of rational overwhelm.

Aftab: Where does this leave us in terms of seeking a scientific explanation of psychosis? Do you see this as imposing constraints on what science can and cannot explain when it comes to psychosis?

Gipps: I’d rather think in terms of exposing possible confusions and conceptual dead-ends than in terms of imposing constraints! What I’ve argued to be potentially misguided are such approaches to delusion formation as consider it to arise as an attempt to ‘make sense of’ aberrant experiences, or that see it as arising out of poor reasoning. Of course, people no doubt do sometimes form odd beliefs in such ways — and I’m not going to police the concept ‘delusion’ and say ‘you just can’t say these are delusions!’ (You can say what you like, so long as you’re clear with us and with yourself about what you mean.) But I do think that Jaspers was onto something when he used the idea of rational/empathic unintelligibility as an index of delusionality. (Which is why he also says that psychological investigations that attempt to retrieve rational sense only offer us “an understandable context for the emergence of certain stubborn misconceptions. If these misconceptions turn into delusion, something new has to arrive”.) What I’d say to the psychopathological researcher is simply this: “Here’s a Jasperian analysis of delusion. He and I have tried our best to do justice to the concept — in particular, we’ve tried to locate what’s delusional, as opposed to simply unusual, erroneous, recalcitrant, etc., in delusional thought. And if we’re right, then the approach you’re entertaining can’t be sound — for if delusion is of its nature that which rebuts rational understanding, then attempts to understand it rationally are going to fail. (Analogy: if it’s of the nature of inanimate existence that it can’t be said to ‘act (or fail to act) on its intentions’, then it’d be senseless to explain the behavior of magma flow in terms of it aiming to go here rather than there.) If, after you’ve considered our analysis, you simply find it phenomenologically and conceptually uncompelling, as not capturing what you and your fellow psychopathologists so much as mean by ‘delusion’, then please just ignore what we’ve said!”

Gipps: I do think that Jaspers was onto something when he used the idea of rational/empathic unintelligibility as an index of delusionality… He and I have tried our best to do justice to the concept — in particular, we’ve tried to locate what’s delusional, as opposed to simply unusual, erroneous, recalcitrant, etc., in delusional thought.

I’d like to point something out about ‘delusions are attempts to make sense of unusual experiences’ type explanations. One of the ways philosophy is helpful is by teasing apart different kinds of explanation. I think I didn’t cover this in my book, but we might also usefully distinguish different ways in which ‘making sense’ obtains in relation to our own experience. What this phrase normally has to do with, as I see it, is making something rationally intelligible, rationally coherent. Thus someone might make sense of it seeming to them that they are seeing pixies in their garden by proposing either that they’ve got Charles Bonnet syndrome or that pixies are in fact real and, can you believe it, hanging out under the apple tree. This is the sense of ‘making sense’ which I, following Jaspers, claim to be off the table with delusion. But there is, I think, another — more specifically psychological — sense of ‘make sense’ which has to do not with a thinker making sense of their experience, but instead with a brain-body-world system being ongoingly moved to enact coherent experience in the first place. Our visual experience sorts itself out into a world with an up and down, distance and foreground, space one can or can’t move into, objects with discrete properties, some things animate, others inanimate, some artefacts, others vegetables, solids and liquids, intentional and accidental movements, etc., etc. Changes in sensory stimulation get, metaphorically speaking, constantly ‘chalked up to’ either environmental changes, or to movements of one’s own body, or to a mixture of these. Now, there ought to be no doubt in anyone’s mind that this form of ‘sense making’ both still goes on, and sometimes goes awry, in paradigmatic schizophrenic psychosis. Our understanding of such (failures of) sense-making, however, is of quite a different form than that deployed when we’re considering a rational subject who’s wondering, say, how to understand how one of their experiences could possibly have arisen. (Holy moly, it sure seemed to me that a striped horse just walked by! Hmm, perhaps a zebra escaped from the zoo… or perhaps I ingested some LSD?) Helmholtz, Gregory, and allied cognitive scientists may have been disposed to conflate these two forms of sense-making in (what I see as) their misleading conception of perceptions as subconscious hypotheses; we, however, needn’t follow them there.

Gipps: There is another sense of ‘make sense’ which has to do not with a thinker making sense of their experience, but instead with a brain-body-world system being ongoingly moved to enact coherent experience in the first place. Now, there ought to be no doubt in anyone’s mind that this form of ‘sense making’ both still goes on, and sometimes goes awry, in paradigmatic schizophrenic psychosis. Our understanding of such (failures of) sense-making, however, is of quite a different form than that deployed when we’re considering a rational subject who’s wondering, say, how to understand how one of their experiences could possibly have arisen.

Aftab: You write, “Psychology as a discipline is notoriously bedevilled by forgetfulness concerning its own past insights into the inner life of psychosis, insights developed, in particular, within phenomenological and psychoanalytical psychology.” (pp. 4-5). What sorts of insights are you referring to?

Gipps: Whilst much of my book is given to the elaboration of the ‘apophatic’ model, I do at other times leave considerations of (the impossibility of) rational understanding aside to focus on positive forms. (In fact, I’d argue that it’s precisely when we appreciate just why rational-business-as-usual models of delusion won’t work that the search for other modes of understanding becomes more compelling.) An age-old psychological insight, for example, is that delusions are at least sometimes motivationally or psychologically intelligible. We can all see just what work the delusion that he’s the King of France is doing for the unemployed and jilted cobbler. This kind of motivational understanding of thought and action, in which we relate the forms it takes directly to the palliation of frustrated desire, the relief of anxiety, etc., rather than to matters of rational sense-making, is a standard issue in psychoanalytic psychology. Another form of understanding that psychologists have offered at least since Jung’s early work concerns psychological symbolism. This has to do with the possibility of reading the content of delusions and hallucinations as we might also sometimes read the content of dreams or fairy tales — i.e., as obliquely revelatory of deeply troubling unconscious emotional predicament. (This psychological concept of ‘symbolism’ is not the same as our more ordinary semiotic conception.)

As for phenomenological insights, what comes to mind now are the contributions of such phenomenologists as would situate hallucinations and delusions within a disturbed self-world experience. Look at the writings of psychologists in the British and American experimental traditions, for example, and you find scarcely a reference to the works of Jaspers, van den Berg, Binswanger, Sass, Parnas, Conrad, Minkowski, Laing, etc. etc. I think that part of the reason for this may be that the way of thinking about mind employed by psychologists — as an inner realm of representations, percepts, or constructs, about which we can only ask: do they accurately represent?, and do they relate meaningfully to one another? — simply leaves no room for thinking about the more foundational strands of mind-world relating as opened up for exploration in particular by Heidegger and Merleau-Ponty. It’s as if the cognitivists’ constructs or representations are supposed to be free-standing, requiring nothing other than causal relations to the body and world to guarantee their meaningfulness. Yet from a phenomenological point of view, the intentionality of any inner representation is parasitic on that of more primordial embodied self-world and self-other relations — and it’s precisely such more primordial strands of selfhood that are disturbed in psychosis. The phenomenological psychopathologists take great pains to describe disturbances in temporality, relation and separation of self and world, corporeality, and interpersonal attunement that precede and ground representational thought. 

Aftab: Unlike many academic philosophers and psychologist researchers, you are also a practicing clinician with a psychotherapy practice that includes patients with psychosis. How does your clinical work inform your philosophical views?

Gipps: I fear I’m most often disappointing in my answer when asked how my philosophy and clinical work inform one another! Psychotherapy is a practical skill which must be picked up on the hoof and honed in the midst of the clinical encounter. And philosophy is another kind of skill which, as I practice it, involves paying close attention to the meaning of what we say, to all the myriad differences between our concepts — and which requires a developed nose for the subtle nonsense that emerges when, as Wittgenstein put it, ‘language goes on holiday’. Because they involve different skills, and someone can be great at one but terrible at another, I think that stories about one informing the other are all too likely to voice post-hoc pattern similarity detection rather than matters of genuine causal influence. What I will say, however, is that I think my clinical work, alongside what is hopefully a nose rather than taste for philosophical nonsense, together help me take a stand against one strand of the now prolific armchair cognitive scientific modeling of delusions or hallucinations or passivity experiences. Many such studies read to me as if they’re undertaken by someone who’s never spent any decent stretch of time with someone in a psychotic state. The depth of personal distress, the brokenness and deep despair, the terrible disappointments in life, the struggles with aggressive and sexual instinct, the temptations toward omnipotent casts of mind, the turning one’s back on intersubjective relating and accountability, the grandiose compensations, the wish-fulfilling delusions, the substitution of private worlds of pseudo-meaning, the unmanageable complexes, the auto-destruction of trains of thought that go too near the complexes: all of this, the actual personal life of the psychotic subject, all too often just goes mysteriously missing from the cognitive models. Their hope, I suspect, is that such deeply personal, affectively charged, matters are secondary to a primary cognitive process that can be worked on with scientific detachment from the armchair. My thought is that this is very likely its own kind of wishful fantasy.

Gipps: Many cognitive studies read to me as if they’re undertaken by someone who’s never spent any decent stretch of time with someone in a psychotic state… the actual personal life of the psychotic subject, all too often just goes mysteriously missing from the cognitive models.

Aftab: You say, “delusional mind is essentially unamenable to a certain kind of (rational) understanding.” (p8) Can you restate what kind of rational understanding you are talking about? What are some ways in which psychosis is amenable to understanding?

Gipps: By ‘rational’ understanding, I have in mind what I believe Jaspers had in mind by ‘empathic’ understanding. This is the kind of understanding which we register as thwarted with such phrases as ‘I didn’t get what you meant’, ‘I didn’t catch your drift’, ‘I just can’t see what he’s getting at’, ‘I just don’t see how she could think that’. It’s a form of understanding that, inter alia, is essentially without method and which is shown, inter alia, in our accurate paraphrases of what others say.

As for other forms of understanding that can sometimes be relevant to answering this or that question we have about someone’s psychotic experience, there are so many! Consider, for example, how the following questions are not merely directed at different aspects of psychotic experience, but are asking for fundamentally different forms of illumination: How does this delusion arise out of, and itself express, someone’s disturbed way of being in the world? What in their neurophysiology makes them prone to fall into such suffering? What’s the relationship between their early life experiences and their current mental disturbance? What emotional pressures precipitate the formation of this delusion or that passivity experience? How does someone’s genotype predispose them to becoming mentally ill? What emotional pressures find symbolic expression in this or that delusion or experience? When my patient isn’t answering my question, is she imagining that we are instead communicating telepathically, or has she obliterated it from her awareness as intolerable, or is she trying to make me feel irrelevant in the way that she often feels irrelevant, or is she conveying her disdain at my asking such a stupid question, etc etc. Why does schizophrenia often develop in late adolescence? What makes the course of psychotic illness different in different parts of the world?

Aftab: “… to encounter another in his psychosis is to visit a site of the tragic and the terrible. For psychotic experience is often terrifying for the sufferer, and even when it isn’t explicitly that, what it constitutes an escape from — terror, brokenness, and overwhelm — often is.” (p6) Doesn’t the idea of psychosis as an escape from terror or brokenness introduce its own sort of function or purpose to psychosis?

Gipps: Yes! I think that psychosis is indeed sometimes psychologically — but NB not rationally! — intelligible in just this way.

Perhaps we can make a distinction between ‘motivation’ and ‘intention’ here, although we should beware of too much ‘tidying up’ of our ordinary language. What I intend is, we might say, given by what I sincerely voice as my intention. Motivational matters, by contrast, have rather more to do with the reduction of tension, discomfort, anxiety, etc. My motives can elude me. I’m at the gym, and putting in a poor performance on the rowing machine. After a while, an attractive young woman comes to use the machine next to mine. Quite soon, I notice that I’m rowing with quite a bit more vigor than before! Did I intend to do so? No. Was my increased performance motivated? Well…

Aftab: What are your issues with the idea that a psychotic individual is living in his or her own private world of meaning?

Gipps: We do indeed say that the psychotic subject is living in his or her own world; with such an idiom I naturally take no issue. My concern is instead to combat the widespread ‘romantic’ idea that whilst both delusions and thought-disordered discourse might, in their different ways, seem to stretch meaning beyond breaking point, really they’re expressive of another form of meaning which we’ve just not yet grokked. As if finding another unintelligible were simply a function of our being boring normies who are too busy holding more psychologically creative and daring types to account in pedestrian, unimaginative, and ultimately irrelevant ways —projecting onto others the rules of the mundane world we live in, rather than attempting to learn the rules of their alternative world! Now, of course, we can all, I hope, think of situations in which something like that has actually happened! But as a rule, it seems to me a disastrous tack to take — often playing both into the omnipotent phantasy of psychotic thought and into what Wittgensteinians call the fantasy of a ‘private language’, and also failing to take a more sober temperature reading of the actual inner and outer predicaments of the psychotic subject.

The issues are complex, so I’ll just refer the interested reader to chapters 4, 8, and 10 of my book. Here I’ll simply note the importance of our ordinary distinction between actual meaning and illusory meaning. We can, all of us, say something which we think is coherent only to later realize that we were tacitly confused. It’s possible to suffer illusions of meaning — both when tackling difficult subjects (e.g. when trying to reason philosophically) and when under significant psychological strain. To have a ‘sense of meaning’, then, needn’t involve your thought being at all meaningful. Too many psychologists simply ignore this fundamental distinction and assume that meaning is a ‘subjective phenomenon’, as if something being actually meaningful could be reduced to the matter of whether you’re disposed to prattle on about it, or thrill to it, or organize your life around it. Accountability of meaning here goes quite out the window, and we’re left in an empty, solipsistic world. For various reasons psychologists have, it seems to me, been far more likely to study illusions of sense (hallucinations, perceptual illusions, etc.) than illusions of meaning.

Aftab: How does your view differ from a view of psychosis as pure dysfunction or pure breakdown?

Gipps: I confess I’m not entirely clear what a ‘pure dysfunction’ view entails. So let me imagine a couple of things and then rebut or agree with them! So, one view might be that we could say what we mean by ‘psychosis’ only by referring to the dysfunctions obtaining in certain psychological and/or neurological mechanisms. I think this cannot be right as an account of the meaning of ‘psychosis’: it would be like trying to say what words mean by giving a physical description of their shapes. Now perhaps we can give a decent causal explanation of why a certain message was misinterpreted by adverting to how the writing was smudged, and perhaps someone could give a decent causal explanation of this or that psychotic experience by describing breakdowns in certain ‘mental mechanisms’. Such an account, however, is merely causal; by itself, it contains no resources to adequately characterize its actual object. When talking about messages, we simply have to invoke the concepts of meaning, communication, purpose, etc. So too, when understanding psychosis, we have to think about what it is that is disrupted (i.e., our rational reality contact). But we can’t say what reason itself is in terms of cognitive mechanisms any more than we can say what visual art is through a pigment analysis.

Another view of what a ‘pure dysfunction’ amounts to could be that delusions, say, can never be considered psychologically meaningful. One finds such views more generally — as to the reality of the unconscious, the meaningfulness of certain dreams or psychotic experiences, the lack of value in attending to free association or the content of children’s free play, etc. — in those who we might style as self-proclaimed ‘scientifically-minded realists’. In truth, these individuals have typically just succumbed to an untenable (because both self-undermining and phenomenologically bankrupt) positivist philosophy which insists that meaning is only enjoyed by such questions and answers as treat of matters in a quantitative fashion. Now I’ve no problem accepting that delusion and hallucination could sometimes be without psychologically tractable underlying causes; perhaps the thyroid, to give a simple example, goes out of whack for no psychologically interesting reason, and perhaps too, and for what it’s worth, such delusions may be treated appropriately with an entirely medicinal approach. I do think, however, that part of what we often mean by ‘mental illness’ is a self-maintaining state that indexes intolerable predicament and its motivated avoidance — and so it seems likely to me that ‘pure dysfunction’ views of the sort just envisaged are prone to encourage an unwarranted faith that the kinds of explanation for such cases as are typically styled ‘organic’ will be found in those more likely to be considered ‘functional’. So far as I can tell, this organic perspective is not really a scientific opinion, one born of empirical experience, but is instead a prayer that a certain reductive program in neuroscience can, despite its present failure to deliver, will eventually come up with the goods.

Gipps: … part of what we often mean by ‘mental illness’ is a self-maintaining state that indexes intolerable predicament and its motivated avoidance…

Aftab: You write about psychosis as an illness: “‘illness’ here functions as something like a metaphor, one which serves to focus our attention on the suffering, the motivation, the internal (self-sustaining) causation, the diminished agency and especially the disturbed rational reality contact here met with.” (p8) Instead of thinking of it as a metaphor, can we not see the notion of illness itself as being broad and accommodating enough to incorporate the suffering, the self-sustaining causation, diminished agency, and disturbed reality contact? This is particularly the case, to my mind, if we understand the general notion of illness as a family resemblance concept or as an imperfect community lacking an essence.

Gipps: It’s interesting to think on how we might settle this question. Before we start, I want to guard against a misguided reaction that some people have to the idea of ‘illness’, in ‘mental illness’, as having a ‘secondary’, or quasi-metaphorical, sense. (A secondary sense application of a term involves us learning it in one semantic context and then just winging its use in another. We start with ‘deep wells’ and end up with ‘deep voices’ or ‘deep troubles’; paintings can now be described as ‘dynamic’, musical themes as ‘plaintive’, landscapes as ‘lonely’, etc.) So, I’ve no wish to say, of someone who is acutely mentally ill, that ‘they aren’t really ill’. They are indeed ‘really ill’ if this means ‘truly mentally ill’, and it would be crass to suggest otherwise! I’m not saying that they’re only metaphorically speaking mentally ill! Another concern arises if our conception of metaphor is of that which can in principle be cashed out in literal terms. Thus, it seems to me that there’s no good reason — despite the efforts of various psychologists — to suppose that psychiatric illness concepts can be translated out without loss into, say, behavioral, cognitive, etc., components. (Thus ‘he’s only ‘ill’ metaphorically speaking; really he’s experiencing ‘distress’’ is, in my view, a truly inadequate take.) It seems to me that talk of illness here opens up (for better or worse) a way of seeing which can’t be captured in other terms. (Hence my talk of the ‘quasi-metaphorical’.)

Gipps: Thus, it seems to me that there’s no good reason — despite the efforts of various psychologists — to suppose that psychiatric illness concepts can be translated out without loss into, say, behavioral, cognitive, etc., components. (Thus ‘he’s only ‘ill’ metaphorically speaking; really he’s experiencing ‘distress’’ is, in my view, a truly inadequate take.) It seems to me that talk of illness here opens up (for better or worse) a way of seeing which can’t be captured in other terms.

Now, using the term ‘illness’ to mean what we might these days disambiguate with the phrase ‘physical illness’ long predated our concept of ‘mental illness’. In using it to cover conditions in which our reason (which in the most paradigmatic cases includes that primordial reason we call ‘reality contact’) is disturbed, we extend its sense beyond that of suffering, self-maintenance, and diminished agency. Furthermore, the sense in which the mentally ill suffer difficulties with agency is different from that in which the physically ill do. (To oversimplify: it’s not so much their actions as their intentions that are awry.) Shall we focus on the differences and see ‘mental illness’ as a quasi-metaphorical extrapolation away from illness (of the body) to that different problem domain of 'illness of the mind’? Or shall we instead insist that ‘illness’ is here used in a similar sense, albeit that there’s no essence and that only some of the features are shared?

Readers interested in this question should I think turn not to my book but to Neil Pickering’s paper ‘The Likeness Argument’ and book ‘The Metaphor of Mental Illness’. Pickering argues, successfully in my view, that those wanting to say that mental illnesses are bona fide illnesses typically foreground the commonalities of mental and physical illnesses, whereas those who argue against it typically foreground their differences. Here then we may often find the tail wagging the dog: those wishing to legitimate or delegitimate the discipline of psychiatry end up emphasizing as analytically significant such features of the ‘illness’ concept as suit their ends. As for myself, I don’t think the discipline should be left hanging on any such project of showing commonalities between mental and physical illness! Just as we may describe a society as sick, so too we may describe a mind as ill. Perhaps the question of whether we characterize this as a metaphorical extrapolation, or as using a family resemblance concept of ‘illness’, doesn’t amount to so much in the end.

Aftab: “… it’s only by understanding that mind here takes an enactive form – one fully immanent within our active and interactive world-engagements, rather than one relegated to a hived-off, inner, domain of representation – that we can begin to understand what it is for us to become unhinged.” (p8) If it turns out that there are indeed such things as representations in the brain (contra pure enactivism), how fatal would it be for your central thesis?

Gipps: My own view is that if ‘representation’ is here being used in anything like it’s ordinary sense, then it could no more ‘turn out that’ there are indeed representations in the brain than it could turn out that triangles have four sides! Leaving that aside: if by my ‘central thesis’ you mean my claim that delusion proper is intractable from the standpoint of rationality, then I don’t see that finding, per mirabile, delusions to be ‘representations in the brain’ need challenge it. Unless, that is, such representations can only ever be predicated of a person in line with something like Davidson’s constitutive ideal of rationality. Even Davidson, however, leaves conceptual room — as we all surely must! — for the concept of an irrational belief, so exceptions must always be possible.

Aftab: What position do you take on the issue of the ‘politics of insanity ascription,’ that is, who gets to claim the authority to decide who is ‘mad’?

Gipps: We do! But who is ‘we’?

There’s a distinctive use of the concept ‘we’ or ‘one’ which we find in discussions of matters semantic and in judgments of ‘common’ sense. ‘By ‘bachelor’ we mean ‘an unmarried man’. OK. But who is this ‘we’? It’s not just ‘whoever means ‘unmarried man’ by ‘bachelor’’, since that would render the original claim entirely empty. But it’s also not some other empirically determined group other than ‘accurate speakers of English’. Again, though, this might be thought to court circularity — since the question could now be asked ‘but who gets to say which are the accurate ones?’ At this point, we can appeal to common usage, to the usage of semantic paragons, to this or that dictionary — but the accusation of question-begging might never go away.

Now, I don’t myself see anything problematic in this circularity. This is after all what ‘bachelor’ means, even if nothing underwrites it other than how ‘we’ competent speakers of English have used and continue to use it. So too, I think, do ‘we’ get to say who is and isn’t insane (is and isn’t ‘in their right mind’). Some of us will be better at this than others, and one hopes that those who go in for psychiatry, and those who learn from their clinical experiences, will be amongst this number. The issue is particularly pressing in psychiatry, however, because those who suffer the most prototypical mental illness are those who may well at times be most unable to acknowledge their lack of sanity.

An important philosophical point here is that nobody gets to be their own judge and jury regarding the rationality of their own thought. To truly be in the rational game is to at least be open to the possibility of peer correction. One of the ways in which the psychotic subject is not in this game is that their judgment regarding the content of their delusional belief is experienced as self-intimating, hence unimpeachable. There just is a chip in their brain; the CIA just is after them: such delusional beliefs aren’t ventured as hypotheses to explain their delusional or hallucinatory experiences; they just come right along with those experiences. If you ask them what could disconfirm their ideas, they’ll not admit that anything could. (Manfred Spitzer has described delusional beliefs as, in this sense, akin to our knowledge of our own sensations.) Perhaps we could say, then, that ‘we’ are those who are still in the game of reason, who are not trapped in that state of mind which Louis Sass styles ‘solipsistic’ in virtue of its remove from a shared participation in reality.

This, of course, leaves open the further question of ‘but whose reality’? In my opinion, such a relativism is utterly hopeless, but you’ll have to read my book to find out why!

Gipps: An important philosophical point here is that nobody gets to be their own judge and jury regarding the rationality of their own thought. To truly be in the rational game is to at least be open to the possibility of peer correction. One of the ways in which the psychotic subject is not in this game is that their judgment regarding the content of their delusional belief is experienced as self-intimating, hence unimpeachable.

Aftab: “The goal is to thereby make visible the suffering of the psychotic subject – including, especially, that suffering which delusion itself aims to evade. And the intent of that is to resource us to retrieve and sit with the patient in her brokenness, rather than to ‘rescue’ her by hallucinating an extant rational order lying behind it.” (p 10-11) There are some who view such talk of “brokenness” as being inherently stigmatizing. Others seeking to humanize and de-other psychosis may be disturbed by your emphasis on characterizing psychotic thought as “not simply puzzling but deeply disturbed – and deeply disturbing.” What would you say to such critics?

Gipps: I’ve never suffered psychosis, but I’ve spoken with many who have, in and out of the clinic, and read the memoirs of quite a few others. I’ve noticed that those who recover from their psychosis don’t tend to baulk at describing their suffering at such times as involving a form of radical rational breakdown (though, of course, one of the interesting things about psychosis is how this can sometimes co-exist alongside intact rational cognition). I’d also say that it’s hard to think of a clearer paradigm of disturbed and disturbing thought than that experienced by the floridly psychotic subject. If this isn’t disturbed, then what on earth is?!

Gipps: I think that a failure to be disturbed by disturbing states of mind can also indicate a failure to really connect with the patient: a too-great comfort with staying in a physician’s patient-as-clinical-object stance.

The world will no doubt always be replete with social justice keyboard warriors who hope that policing other people’s language use will somehow count as morally meaningful work. I haven’t yet found a compelling reason to take these people seriously. There is, however, also another problem, an occupational hazard, to contend with — which is when, as a psychologist or especially a psychiatrist, one stops finding disturbing the patient’s psychotic state of mind. Maybe this makes ward rounds possible (which isn’t necessarily a bad thing); maybe some degree of it is procedurally helpful to the busy doctor. And sometimes, after all, our feeling disturbed is simply a function of unfamiliarity, or of unhelpful expectations. But I think that a failure to be disturbed by disturbing states of mind can also indicate a failure to really connect with the patient: a too-great comfort with staying in a physician’s patient-as-clinical-object stance. Now the goal becomes just one of trying to restore sanity from without, rather than building a genuine subject-to-subject relation from within. Perhaps sometimes all one can really do is humbly wait until a psychotic fire burns out, often with the aid of tranquilizing medicaments. And yet here too, I find myself sympathetic with Wittgenstein in the following conversation from the late 1940s with his ex-student and friend, the psychiatrist Maurice O’Connor Drury: Drury: “Some of the patients I am seeing present symptoms which I find extremely puzzling. I often don’t know what to say to them.” Wittgenstein: “You must always be puzzled by mental illness. The thing I would dread most, if I became mentally ill, would be your adopting a common-sense attitude; that you could take it for granted that I was deluded.”

Aftab: Thank you!

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