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  • Madness, Moral Agency, and Recovery
  • Neely Myers (bio)

All the world's a stage,/And all the men and women merely players; They have their exits and entrances; And one man in his time plays many parts.

William Shakespeare, As You Like It, Act II, Scene VII, Line 139.

This piece, co-authored by a doctor and patient in dialogue with one another, points to the promise of prioritizing moral agency in clinical interactions and how this can promote recovery. This response will consider the broader social, philosophical and clinical context of madness in the United States. It will also signal the relevance of this piece to the larger body of work about recovery and mental health services. Finally, it will indicate the implications of this piece for existing mental health services and best practices, especially shared decision-making.

Madness in context

For the past 50 years, self-described "mad" persons in the United States have been culturally renegotiating the understandings and treatment of madness. As mad persons share their stories, we learn that madness today is also often temporary, intermittent, manageable with the right supports (including, for some, good psychiatric care) and at times profoundly spiritual and valuable (e.g., Chamberlin, 1997; Crowley, 1996; Deegan, 1993; DuBrul, 2014; Fisher, 1994; Frese, Knight, & Saks, 2009; Jones & Kelly, 2015; Saks, 2007; Steele & Berman, 2001). Many mad advocates foreground the concept of "recovery"—the notion that in the right setting, with adequate resources, hope and personal support people can thrive in spite of the misfortunes madness may invite (Ostrow & Adams, 2012; Ridgway, McDiarmid, Davidson, Bayes, & Ratzlaff, 2002; Torgalsboen, 2005). Mad advocates, using a variety of terms, are working to recover the right to be the authors of their own lives—and of madness in general.

My ethnographic research has closely followed stakeholders' efforts to reform the American mental health care system based on the notion of recovery put forth by mad activists since 2002. The concept of recovery pushes back against the notion that madness is a transgression—a violation of collectively agreed upon social, moral and legal boundaries. Madness became a transgression rather than a potential sacred power or source of amusement when the public began to exclude mad people as irrational, immoral, unhealthy or dangerous for the public good because they could not work to earn their keep (Eghigian, 2010; Foucault, 1965; Grob, 1994; Porter, 2002; Shorter, 1997; Warner, 2004). By working and living fulfilling lives "in recovery," mad people transgress [End Page 31] the notion that madness is a permanent state of chronic deterioration or increasing dementia, as mentioned by LG and GS in this article. Foucault feared that the exclusion of mad people would be permanent, but overlooked the possibility that the exclusion of the mad was "merely a displacement, a knee-jerk reaction" that could be culturally renegotiated, as has been slowly done by the mad activists and recovery-oriented activists, clinicians and researchers in the United States (Boyne, 1990; Myers, 2015).

Moral Agency and Recovery

Based on my research with people in recovery, people trying to promote recovery, and people trying to prevent the need for people to have to recover in the first place, I have argued that "moral agency" is crucial for recovery in the aftermath of the medical, legal and social response to psychosis. Moral agency, or the ability to help others see one as a "good person" worthy of intimate connection, is moral because it is based on local notions of what is "good"—not some higher moral code. And it has to do with agency because one must be able to act on it. I have argued that in the United States moral agency is needed to access the intimate relationships that one needs to recover (Myers, 2015). I have shown that moral agency is nourished in one's life in the United States when one has the intention and resources to exercise three key capabilities: autobiographical power, or some control over the way one's life story is told; the ability to be recognized by others as a "good" and valued person, or the social bases of self-respect; and the opportunity to try (and...

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