Joanna Moncrieff

Philosophy Part 1: Why philosophy matters!

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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:

  1. Szasz, T. (1961) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper.
  2. Szasz, T. (2000). Mental disorders are not diseases. USA Today, January issue.
  3. Parsons, T. (1951). The Social System. London: Routledge and Keegan Paul.
  4. Szasz, T. (1989). Law, Liberty and Psychiatry: an inquiry into the social uses of mental health. Syracuse, New York: Syracuse University Press.
  5. 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

 

 

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