This is the first of a series of blogs presenting a philosophical analysis of the modern mental health system and what it is concerned with.
20th century philosopher, Ludwig Wittgenstein, much of whose later work concerns our thinking about the ‘mind’, suggested that the role of philosophy is to identify and clear-up conceptual confusions. Many of these confusions have been introduced by philosophers, asking the wrong questions in the wrong way. Wittgenstein hoped to show that by understanding the nature of language more accurately, many of the most complex dilemmas of philosophy just melt away.
This idea of tidying up our language might sound like a rather modest activity, of little practical importance, but it is not just philosophers who have been beguiled by muddled uses of language and led astray by fruitless debates. These confusions have permeated everyday thought. They influence our behaviour as individuals, and structure the social institutions we build. Nowhere is this more apparent than in the system we now call ‘mental health.’
Thomas Szasz is, of course, the most well-known person to have called attention to the conceptual confusion embedded in the term ‘mental illness’ (1). For Szasz, illness and disease are concepts that are inextricably bound to the body, hence a non-bodily, non-material concept such as the mind cannot be ‘ill’ (2). Situations that are referred to as ‘mental illness’ are defined by certain sorts of problematic behaviour, not by the biological dysfunction that is characteristic of regular illness. Szasz also understood that the confusion inherent in the concept of ‘mental illness’ did not simply arise because people were misguided, it is what he called ‘strategic.’ Designating certain problems as ‘mental illness’ justifies particular social arrangements and it does so because the terms ‘illness’ and ‘disease’ derive their meaning from being a condition of the body.
I will return to the crucial issue of whether or not an illness is necessarily a bodily characteristic in later blogs, but now I just want to illustrate how important this question is. Whole social systems depend on the assumption that what we call ‘mental illness’ or ‘mental disorder’ (a piggy-back term) originates in the body. In particular, this notion is fundamental to the current social response to certain forms of behaviour, and to processes for allocating resources for assistance or welfare.
In modern societies, the use of force by some individuals against others is considered unacceptable and is illegal. The state reserves a right to use force in some situations, but only against those who have broken the nationally agreed code of conduct – the law. However, if someone’s thinking and behaviour are thought to be the result of an aberrant biological process taking place within the body or brain, a process that has nothing to do with the personality or agency of the individual (which is what I will argue is the usual understanding of the term ‘disease’), then the individual logically forfeits the right to be regarded as an autonomously-acting being. What she does and says in these circumstances can legitimately be disregarded. Efforts to change her behaviour, which may involve the use of force, can be conceived of as a medical ‘treatment’ that is aimed not at the individual per se, but at the underlying disease.
Think of the contrast between compulsory community treatment orders or outpatient commitment for people diagnosed with mental disorders and the use of libido-suppressing agents for sex offenders (sometimes referred to as chemical castration). Although these drugs can be imposed on convicted offenders as part of sentencing in some parts of the world, in most of Europe, sex offenders have to give their consent, and in the United Kingdom, a second opinion is also required for the drugs to be administered by injection. Under out-patient commitment laws, someone who has a diagnosis of mental disorder, but has never harmed anyone, can have her body chemically altered against her will for the rest of her life, despite having the capacity to make a perfectly rational decision about this for herself. This is not imposed as a punishment for misbehaviour (at least not explicitly), and would not be acceptable in modern, western society without the implicit assumption that having a ‘mental disorder’ is equivalent to having a bodily disease. This enables the expressed wishes of the individual to be disregarded since she is no longer viewed as an autonomous agent, but as an object that is driven by the biological process taking place in her brain.
The idea that mental disorder is a disease is also the basis of modern welfare systems and crucially important for enforcing the modern work ethic. The characteristics of the ‘sick role,’ described by Talcott Parsons, derive from the nature of diseases as biological processes. People who have a disease have exemptions from normal social expectations and entitlements to care and support because of the recognition that biological events are not (often) under human control (3).
Modern society has no other way of excusing people of their social obligations. Although we recognise that numerous common life events (relationship breakdown, loss of a job) can make it difficult for people to cope with their daily duties, only a medical certificate verifying that someone is ‘sick’ (the ‘sick note’) entitles them to time off work, or financial assistance without the obligation to seek work.
I am not claiming to say anything new here. Szasz has made these points for decades (4). There is a tendency within mental health circles to fudge or avoid the issue, however. Proponents of the ‘biopsychosocial’ model appear to suggest that mental disorders can be both a biologically-driven process and a behavioural condition at the same time. Others claim that mental mechanisms and biological processes are the same thing, and hence can be sick or diseased in the same way (5). Although the term ‘mental disorder’ appears to avoid criticisms of the concept of mental illness, in reality it serves the same purpose, and hence ‘piggy-backs’ on the concept of mental illness.
I simply want to stress that fundamental aspects of western society depend on the equation of certain social problems with bodily conditions or illnesses. Without this, the concepts of mental illness or mental disorder cannot do the work they currently do. They cannot form the basis of the social systems they currently sustain.
What disease or illness is rightfully thought to be, and whether these concepts should, or should not, include the problems we refer to as ‘mental illness,’ has hugely significant consequences. It turns out that clarifying conceptual confusions may have a profound impact on modern society.
In the next blog in this series, I will look at the philosophy of Wittgenstein in more detail, and how it relates to our understanding of the ‘mind’ or the ‘mental’
Notes:
- Szasz, T. (1961) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper.
- Szasz, T. (2000). Mental disorders are not diseases. USA Today, January issue.
- Parsons, T. (1951). The Social System. London: Routledge and Keegan Paul.
- Szasz, T. (1989). Law, Liberty and Psychiatry: an inquiry into the social uses of mental health. Syracuse, New York: Syracuse University Press.
- I am referring here, among other’s, to Jerome Wakfield’s ‘harmful dysfunction’ hypothesis of mental disorder: Wakefield, J.C. (1992) Disorder as harmful dysfunction: a conceptual critique of DSM-III-R’s definition of mental disorder. Psychological Review, 99, 242-247
Joanna Moncrieff 
Thank you for a very interesting article. I am already curious about the next one. I think the disease model of mental illness makes people think that the disorder speaks for the patient. (Sometimes people talk about themselves in this way, that is another interesting philosophical theme.) If a person is diagnosed as mentally ill and she doesn’t want to take drugs, it’s the disease speaking for them. Somewhere inside them, there is a “normal person” who would agree to treatment.
The problem is, that people in power can always use this rhetoric. (Szasz has written extensively about this.) In a communist country, a person who speaks out against communism can be called mentally ill and treated with medication, because any sane person would heartily agree with the state ideology.
So if a sane person would take drugs and only a sick person would refuse them, there is no possible alternative but to comply with treatment. One way to deal with this problem would be to recognize the human rights of mentally ill people and to offer them a safe place, time, and patience to deal with their problems in life. The exact same things that any other human being would need in such circumstances.
Gotta disagree. The concepts don’t arise from the words. It’s the other way around.
As you point out, euphemism creep has already set in to the point where ‘mental illness’ and ‘mental disorder’ have essentially become the same thing in terms of stigma and power relationships. We can call it ‘illness’, ‘disorder’, ‘aberration’, ‘variation’, ‘deviance’, ‘criminality’, ‘demonic possession’, ‘special needs’ or anything we like but if the essential authoritarian attitudes and the social need to create hierarchies and underclasses remain the new words will always converge on the old meanings.
Let’s not forget the disease model is flogged as a more humane alternative to the criminality model, but the latter is always waiting in the wings ready to take up the slack if the former fails. That’s because ‘mental illness’ is really just a euphemism for what many consider to be moral failings. Szasz himself was no slouch when it came to attributing criminality to those who invoked the ‘insanity defence’ and moral weakness to those who invoked mental illness to excuse themselves from working. Is that really an improvement on what we’ve got?
That said, conceptualising human suffering and non-conformism as disease has enabled a huge industry of quacks to stake it out as their expert domain. I guess whether you prefer authoritarian medical quacks to judicial, political or clerical ones is mostly a matter of taste, though Foucault makes a strong argument that medicalised oppression is worse.
Thank you both for your comments. in response to kayakangst, I think the idea that the ‘disorder speaks for the patient is very powerful.’
In response to cabrogal, I think the illness model avoids some very difficult social issues, which do not have easy answers. Although the idea that certain behaviours are illnesses may avoid blame and punishment, it is accompanied by a loss of autonomy, which can be a high price to pay.
I wonder if I made my point clearly.
I don’t think the illness model avoids blame or punishment – at least not for the sufferer. There’s a substantial body of research suggesting ‘brain disease’ models increase stigma – especially from clinicians – and those detained under mental health legislation (here at least) are not only likely to get longer sentences (often indefinite) and greater loss of rights than ‘criminal’ prisoners, they can also be locked up not for things they have done but for what some quack says they may do.
If the model reduces blame it’s of the family and carers of the sufferer, which is no doubt why organisations like NAMI are so attached to it.
The point I’m making is that you don’t reduce social oppression by fiddling with words. At best you cover it up a bit and allow middle class liberal types to go about their business imagining they live in a just and humane society. If you change the words without changing the attitudes and mechanisms of oppression you have achieved nothing. And the medical model is not a mechanism of oppression, it’s an expression of those mechanisms. The need of Soviet authorities to suppress dissent came first. ‘Sluggish schizophrenia’ followed.
Doctors in the southern US don’t talk about drapetomania anymore. But it wasn’t changes to medical textbooks that freed the slaves. It was a war. And there are still any number of institutional mechanisms for punishing black people who ‘step out of line’.
‘Autonomy’ is actually a huge philosophical question that hinges on the age old unresolved dialectic of ‘determinism vs free will’. You don’t need a brain disease model to be able to claim someone lacks it and treat them accordingly. We do it to children, animals, minorities, people who don’t share our political or religious beliefs and many others, without recourse to medical ‘experts’.
I agree that suggesting that mental illness has a physical basis serves as a justification for psychiatric treatment and intervention but look forward to your further thoughts on whether or not an illness is necessarily a bodily characteristic.
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Hmm then why isn’t there compulsory treatment for physical disease? Mental illness may be a confusion but logical conclusion of way you argue this is that both or neither attract coercion. It’s surely the very ambiguity of the category that allows coercive responses. Wittgenstein not a ‘language clarified’ but also study ambiguity and liminality and how they circulate in local contexts. Making whole world clear by language laundering lost cause – universalist and weirdly realist ontologically.
I’m reserving judgement until I hear how Dr Moncrieff applies Wittgenstein but I’d too would have thought his argument that meaning is not intrinsic to words but arises from their use within a socio-cultural context would make it hard to claim that changing words would make much difference. Maybe not ontological realism but but an anti-nominalist social constructionism? Double plus odd.
Hi Diana,
good point. It is specifically when thinking and behaviour are thought to be the products of disease, that the idea of disease can be used to legitimate the use of force. Otherwise, as you suggest, we allow people to make their own decisions about what is done to their bodies, and whether to accept treatment for a disease.
Yes, but that just points to how irrelevant “disease” is to legitimising force. It’s the anticipated behaviour attributed to the ‘patient’ that justifies the force, not the disease. Specifically it’s allegedly being “a danger to oneself or others”.
“Disease” is a way of adding bogus authority to behavioural predictions by placing them within the realm of a technocratic elite that is assumed to have the patient’s best interests at heart (i.e. doctors). There are non-medical elites who would serve if “disease” was abolished.
”Under out-patient commitment laws, someone who has a diagnosis of mental disorder, but has never harmed anyone, can have her body chemically altered against her will for the rest of her life, despite having the capacity to make a perfectly rational decision about this for herself.”
Yes, and then when you consider that many medical ‘treatments’ which psychiatry and medicine have in abundance can cause harmful effects to many, whether they are committed or not, it is no wonder that so many people are misunderstood and harmed!
http://www.mindfreedomireland.com
How good it would be if people who were trained professionally learned to speak simply! If you have a good idea it is important use language people in general understand.
I look forward to more of these
Thank you
I agree that changing words will not necessarily make a difference, but to in order to examine our current system properly, and to imagine different ways of doing things, we need to clear up the conceptual muddle it is based on.
‘in order to examine our current system properly’ People have to listen first and as you have found that doesn’t happen. I’m on my second try with the PHSO. If this time round goes the course, amongst other things, I’m going to be asking if they can help you get the message across to head honcho Doc Wessely and his gang at the Royal College of Psychiatry, bit of a long shot, but you never know.
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Philosophy itself has the complexity and contradiction, which makes a considerable number of scholars at home and abroad to explore and study it. Once the researchers become fascinated, the spirit becomes confused.
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