The Remnants of Sense

Abstract

The Remnants of Sense Alastair Morgan, PhD (bio) In an interview outlining her approach to understanding mental distress, Lucy Johnstone states that when faced with ostensibly bizarre, irrational or distressing experiences: [T]he guiding principle of "At some level it all makes sense" applies. In fact, I can't immediately think of anyone I've worked with for whom it did not, in the end, turn out to be true.1 The two commentaries on my paper point to two levels where this sense-making might operate; a structural and an individual level. Havi Carel (2023) draws attention to the important concept of power in the Power Threat Meaning Framework and suggests a widening of the concept of threat to a concept of vulnerabilization that refers to the multiple factors that expose people to institutional neglect and violence that is interlaced with a range of forms of discrimination, neglect and disadvantage. Whilst the main strength of the PTMF approach is to draw attention to the structural importance of power in contributing to forms of psychic distress, the emphasis on a concept of threat tends towards a reactive and reductive concept of power. Carel (2023) helpfully points to a wider concept of power that can be utilised for further work in understanding the impact of societal violence on forms of mental distress. Such a widening of the concept of power does not only rest on a critique of institutions but also an understanding of the ways in which people can be abandoned and neglected by state support of one kind or another. Power operates through a dual logic of exposure and abandonment. Some people are particularly exposed to forms of institutional power from an early age and vulnerabilized by such exposure, but there is also a logic of abandonment within such exposure; the ever present possibility of neglect. Such an operation of power is not univocal (or embedded in one profession) but dispersed and differentially applied. As Didier Fassin (2018, p. 43) writes: "All lives are precarious but certain lives much more so than others—and above all, quite differently." Psychiatric power is one important focus when trying to understand this process of the exposure and abandonment of power, however, as Carel (2023, p. 75) notes, "the medical realm is not its own kingdom." Psychiatry is inserted into a network of dispersed power that has multiple and differential effects, both positive and negative. The focus on the question of psychiatric diagnosis as the apotheosis of societal power neglects the multiple effects of diagnosis or the lack of diagnosis on people who are particularly vulnerable to the operations of power. In situations where institutional care is crumbling and under-resourced the focus on psychiatric care alone as a problem of power risks just compounding such an institutional neglect. [End Page 77] Veena Das (2020) asks the question of what happens before the arrival of the psychiatrist on the scene of care and after her disappearance. Das (2020, p. 174) is interested in the multiple ways that power flows across and between both formal and informal institutions to produce a "milieu of madness." Such flows of power will also apply to increasingly hegemonic psychological formulations of signs of distress as problems in living, as problems in adaptive reactions to adversity. Such formulations are themselves inserted into a nexus of power relations and processes of vulnerabilization and are not somehow free of the taint of other forms of understanding. Indeed, as Carel notes, the process of demedicalization and de-professionalisation can very easily be inserted into the dual logic of exposure and abandonment that I discussed earlier. People can be exposed to power in a wider range of settings as psychic distress is demedicalized but also subjected to abandonment and neglect as mental distress is no longer thought of as an illness but just one of many wider and non-medical problems in living that does not require state support. The structural account of the determinants of mental distress offers an important corrective to individualised and medicalised approaches to meaning, but doesn't completely erase the problem of understanding and interpreting mental distress. Mohammed Abouelleil Rashed's commentary raises important issues with the...