In this blog I want to come back to the work of Thomas Szasz. The last two blogs argue that bodily states and processes need to be understood in a different way from the way we understand what human beings think and do. Mental ‘illness’ consists of things that people say and do. For Szasz, an ‘illness’ means a condition of the body, and hence mental illness is not an illness.
According to Szasz, the term ‘disease’ (in its proper and coherent use) refers to changes in bodily structures or mechanisms that produce unwanted physical sensations and experiences, otherwise known as ‘symptoms.’ ‘Illness,’ on this account, is the subjective experience that arises as a consequence of the presence of disease in the body.
On this view, a disease, in its core sense, is a property of the biological system known as the body. Hence, diseases can be described in material terms, and can be understood according to general biological principles that are independent of the individuals they affect. Diseases unfold in more or less predictable ways according to their biological nature. Cancer cells multiple and disseminate, eventually impinging to such an extent on other cells that the organs cease to function. Narrowing of the arteries supplying the heart leads to angina and heart attacks, known as coronary heart disease. It may be possible to influence the course of a disease by modifying one’s body and its environment, such as stopping smoking or getting treatment, but you cannot simply wish a disease away (or so it is generally believed). Biological systems, like chemical and subatomic reactions, are governed by predictable regularities that have nothing to do with the desires and purposes of human beings.
Little attention has been paid to the question of whether or not a disease is necessarily a bodily condition. This seems to be because philosophers of biology or disease who are not principally concerned with mental disorder just assume it to be the case, whereas those that focus on mental disorder usually ignore the issue. The French philosopher of biology, Georges Canguilhem, for example, states that ‘one can speak with reason of “Greek Medicine” only from the Hippocratic period onward-that is to say from the moment when diseases came to be treated as bodily disorders’ (1) (p 35).
Many thinkers who are concerned to encompass the realm of mental disorders within medicine, implicitly suggest that the terms ‘illness’ and ‘disease’ do not need to refer to the body. They argue that what is essential to these concepts is the fact that they represent disvalued or unwanted states. Peter Sedgewick, for example, points out that there are no diseases in nature (2). Beyond their ability to cause pain and death, the consequences of physical conditions depend on social expectations and demands. Mild arthritis in the hands may be highly problematic to a violinist, but irrelevant to most of the rest of us. Industrialised societies organised around the productivity of wage labour heighten the impact of chronic conditions that reduce performance, which may be better tolerated in rural societies with more communal traditions.
Sedgewick is right to point out that whether the body functions adequately depends on its environment and the demands it has to meet, and these demands in turn depend on the conventions and expectations of a given society. Simply being a feature of the body is not enough to qualify something as a disease. There is also a value judgement involved about the consequences of that condition and the benefits of treating it, which will differ from one context to another.
But Sedgewick and others take the argument a step further and suggest that it is the disvalued nature of disease that is central to the concept, and therefore that other situations involving a negative value judgement can also be called a disease or illness. This is tantamount to saying that any unwanted situation can be considered to be a disease.
In response to this value-based definition of disease and illness, some thinkers have tried to reinstate objective criteria that can encompass mental disorders alongside bodily conditions. Arguing that physical or biological mechanisms and ‘psychological mechanisms’ can be thought of as equivalent, they extend the concept of illness to include situations, such as those we refer to as ‘mental disorders,’ that are defined by the presence of unwanted behaviours. Hence psychiatrist Robert Kendell argues that ‘the differences between mental and physical illnesses, striking though some of them are, are quantitative rather than qualitative, differences of emphasis rather than fundamental differences’ (3) (p 42).
Jerome Wakefield’s much-discussed concept of ‘harmful dysfunction’ is an example of this thinking (4). Wakefield elides bodily dysfunction and psychological dysfunction by claiming that both are objective situations that can be defined by a failure to fulfil evolutionary purposes. However, just as the fact that cancer and crime are both negatively valued situations does not render them the same kind of thing, the idea that mental and physical mechanisms might both be evolved also does not confirm their equivalence. Our ability to be flexible and adaptable, in other words our free will, can be seen as an evolved phenomenum, but this doesn’t make human behaviour the same sort of thing as the structure of the eye or the dexterity of our hands.
Moreover, Wakefield’s reliance on evolutionary theory adds no value to the understanding of physical diseases, let alone the definition of mental disorder. Medicine uses mechanistic not adaptive explanations of function. We define the normal function of the heart, for example, as the level of functioning required to keep the rest of the body alive and well. There is no need to postulate natural selection or an evolutionary teleology (5). Indeed, evolutionary psychology has been the subject of extensive criticism, and its claims to objectivity have long been recognised as spurious. It is shot through with evaluative judgments about what ‘normal,’ ‘natural’ or ‘proper’ mental functions and behaviour consist of (6).
By equating psychological and biological dysfunction Wakefield is ultimately suggesting, like Sedgewick, that there is no value in the distinction between an unwanted condition of the body and other problematic situations. Yet this is surely not true. It is evident that in real life we find it important to distinguish situations that arise as a consequence of a bodily state or event, and those that are manifestations of what we recognise as human behaviour, that is activity initiated by an autonomous, self-directing individual. Consider the importance of distinguishing ‘real’ epileptic fits from ‘pseudo-seizures’, for example! We treat people who ‘fake’ fits, consciously or unconsciously, differently from people whose fits originate from abnormal electrical impulses in the brain.
Working in a drug detoxification unit this is a real, everyday problem. People who have been using large amounts of alcohol or benzodiazepines are liable to have epileptic fits during detoxification, which can be dangerous and life-threatening and need immediate treatment with benzodiazepines or other anti-epileptic agents. People with a history of addiction may also fake fits in order to obtain these substances, however. If you give people who fake fits anti-epileptic drugs, you not only expose them to unnecessary harm, you also undermine the ethos of the recovery programme for everyone in the unit.
We make an effort to distinguish these different situations because they call for a completely different understanding and response. Making the distinction matters.
Szasz did not deny, as is sometimes implied, that the concepts of disease and illness are what is referred to as normative- that is they incorporate value judgements about what is ‘normal’. He merely observed that wanted or unwanted, bodily conditions can be described in material, biological terms: ‘although the desirability of physical health, as such, is an ethical norm, what health is can be stated in anatomical and physiological terms’ (7)(p 14). If you loosen the association between the concepts of illness and disease and the body, you empty them of their distinctive meaning. They are no longer able to pick out a particular category of unwanted situations and become synonymous with generic terms like ‘problem’ or ‘difficulty’. Divorced from the body, the words cease to have any discriminative power. They become meaningless.
In the next blog I shall address the idea that mental disorders are, in fact, diseases of the body – in particular that they are brain diseases.
References
(1) Canguilhem G. Writings on Medicine (Forms of Living). New York: Fordham University Press; 2012.
(2) Sedgwick P. Psychopolitics. London: Harper & Row; 1982.
(3) Kendall RE. The myth of mental illness. In: Schaler JA, editor. Szasz Under Fire.Chicago: Open Court; 2004. p. 29-48.
Joanna Moncrieff 
How would you factor “labeling theory” into your ideas? I refer to Thomas Scheff’s book BEING MENTALLY ILLL as a good example.
Have you discussed issues of “free will”?
What I’m going to say below may not be totally germane to your writings, but I’d like to take the chance to “put it out there.”
As a mental patient child of mental patient parents who harmed me and were harmed by their parents, I think of “mental illness” as being important “nurture” issues, with also “nature” issues going on too. Genetic endowments give variable talents and challenges that play out in in society and culture mediated by resources and understandings. My parents might have behaved differently and harmed me less, but neither the “physical” or “mental” alone gives a full explanation of what they did. Also, some of their worst acts toward me came out of their own profound suffering. I don’t think philosophy can deal effectively with that suffering. We need some understanding of culture, social interaction, demands of living socially…. and more from other sources, spiritual maybe….
Thank you.
Dear Saragale, I think my ideas are quite consistent with labelling theory, that is that cultural expectations people’s influence behaviour. There is some really interesting literature about how cultures like Eastern Europe and Japan had no real concept of depression, until it was introduced by the pharmceutical industry. the implication is that people express their suffering in different ways, according to what templates are culturally available. Having said that, I don’t feel labelling theory adequately deals with the issue of where the problems come from in the first place.
Free will is coming next!
I agree that biology helps determine our character and abilities, which shape our behaviour. But I don’t think this is the same thing as saying that biology is a single or partial cause of mental disorders. I also agree that philosophy is not enough to understand or address suffering. In a previous blog I suggested that the arts and humanities are what illuminate the nature of suffering and help us to overcome it. Here I am using philosophy to try and untangle what I regard as misunderstandings in the way we think about ‘mental disorders’.
There might be more to labeling theory than you realize. I don’t feel comfortable with your arguments, but I don’t have the erudition or will to confront your reasoning effectively. I think what you are doing is “motivated reasoning” starting with the belief that illness if of the body. Thank you.
Psychological dysfunction isn’t meaningless, is it? I agree there may be disagreement about what counts as psychological dysfunction, but the point is that what is identified as schizophrenia, for example, is a functional rather than structural brain disorder.
Hi Duncan,
The point I was trying to make in this blog is that ‘psychological dysfunction’ is not properly thought of as a disease or illness, because those concepts are inextricably linked with the body. However, I am not sure that it is a very meaningful term. Going back to Wittgenstein, when we use the term ‘depression’ for example, or madness or psychosis, what we are referring to is a certain pattern of behaviour that we recognise in other people – not a private experience in our own minds. We come to apply the term to our own experience only secondarily, after we have learnt its meaning from the public sphere. This is view has been fleshed out by anthropolgists, such as Vieda Skultans, who show that the nature of distress is shaped by the templates that are available within a culture https://www.ncbi.nlm.nih.gov/pubmed/?term=skultans-v+and+depression
Moreover, the idea that the behaviours we refer to as ‘mental disorders’ are caused by a psychological dysfunction is also misleading, because you cannot separate our ‘psyche’ from our behaviour in the way that would be required for events in one to cause the other. So I am not sure that ‘psychological dysfunction’ is a meaningful phrase. At least, I do not think it adds anything to a description of behaviour, as long as that description is one that recognises that human behaviour is the expression of a thinking being (i.e. not just the crude behaviourist view).
Of course psychological dysfunction is dependent on the brain. Anatomoclinical understanding of illness, in terms of describing physical pathology, is a relatively recent understanding of illness from the nineteenth century. I agree psychiatry hasn’t fitted very well with that way of understanding illness. But to restrict illness to physical pathology is missing the point. People go to their doctors for wider reasons. And I agree madness/psychosis may well be defined by others but it’s that ‘loss of touch with reality’ that encourages us to view it as illness. Something has ‘gone wrong’ with mental functioning. I don’t want to get too caught up in semantics, if that’s all our disagreement is about, but I suspect it does have wider implications, as for example, I do see psychiatry as part of, if not central, to medicine.
Hi Joanna
I think you are wrong to say that Peter Sedgwick effectively argues that “any unwanted situation can be considered to be a disease”. This is the argument Wakefield makes against him and which I examined in my article on Sedgwick from Critical and Radical Social Work, 3 (1): 103–17, in 2015. I quote the relevant passage:
“A more sophisticated charge has been made by Wakefield (1992), whose influential ‘harmful dysfunction’ analysis of mental disorders treats these as existing ‘on the boundary between biological facts and social values’. Wakefield contends that ‘the fact that all disorders are undesirable and harmful according to social values shows only that values are part of the concept of disorder, not that disorder is composed only of values’. He argues that Sedgwick provides no consistent guide as to how to differentiate (health) disorders from other forms of social deviancy, and that this results in his being unable to critically analyse ‘incorrect diagnoses’ such as the historic labelling of runaway slaves and Soviet dissidents with mental illness. In addition, situations where there is an ongoing dispute about the disorder status of a particular problem (eg, attention deficit hyperactivity disorder [ADHD] or alcoholism), ‘[t]he complex factual arguments presented by both sides in these debates clearly indicate that judgments about disorder depend on much more than values’ (Wakefield, 1992: 375-7).
“Yet Sedgwick did not dismiss the facts presented in favour or against whether something is considered to fall within the health-illness spectrum and whether it represents disorder. Rather, as a historical materialist, he saw ‘facts’ as indissolubly bound up with the human social practices in which they were apprehended and ‘discovered’. He was making an ontological point: that human conceptions and the material reality they described were not the same thing. Thus, arguments about the ‘medical’ status of some social problem – or even if it is a ‘problem’ at all – can only be understood in a historically grounded appreciation of the society in which such debates occur. Sedgwick wrote of such definitions emerging because of the human interests they serve – but he also dissected the complex and often antagonistic ensemble of social interests that operate in any particular historical epoch. The implicit charge of relativism levelled at Sedgwick therefore does not apply. Unlike even an erudite analyst like Peter Conrad, whose accounts of medicalisation detail the competing social interests influencing such processes but refrain from making judgements about whether medicalisation is valid in each case (Conrad, 2008), Sedgwick based his judgements in an immanent critique of existing society. Except, perhaps, for his brief dalliance with a Kropotkin-influenced view of alternative healthcare systems at the end of Psychopolitics, his judgements are grounded in the impossibility of drawing up blueprints for healthcare in an idealised future social order. This does not restrain him from making judgements about, say, the extreme individual libertarian views of someone like Szasz, on the basis that beneath the arguments lie determinate social interests, expressing themselves as absolute principles or objective facts when in fact they cannot be separated from the historically specific social purposes they reflect at the level of ideas, whether or not such mediations are consciously understood by those making them. In the end, Wakefield’s goal of a methodology that can come to objective conclusions about what is or is not a mental disorder cannot be satisfied precisely because he wrongly presumes that the answer can be judged independent of such interests. While standing against positivism at one level, Wakefield invites it back in at another.”
In summary, I think Sedgwick is arguing that the critique of concepts of health and illness is inseparable from a critique of society that produces these definitions. To try to deny that mental health and illness are “real” health and illness is to simply try to impose our preferred definitions over how really-existing society has produced those definitions, as if we are privy to some deeper truth inaccessible to the rest of society.
Tad
Really sorry, but the common psychosomatic symptoms (palpitations, muscle weakness, anxiety, insomnia0 are features of Magnesium deficiency, of which between 150-20% of us are prone to. he problem is that intracellular Magnesium is difficult to measure, has not much relation to serum Magnesium. Magnesium also has protective effects on the cardiovascular system and hypertension / diabetes, again seen as common psychosomatic illnesses.
Furthermore, a lot of us are deficient in Vitamin D, especially during the winter period when exposure to sunlight is poor, worse in people of colour. Supplementation appears to have an ameliorating effect on flu (as strong if not stronger than the flu jab). So, rather than blaming ‘psychosocial stress and deprivation’0 maybe we need to be doing the ‘bleeding obvious’ and take appropriate supplementation.
Dr de Silva
Senior Lecturer, faculty of Health Sciences and Wellbeing
References
1. Fang, x., Wang, K., Han, D. et.al. Dietary Magnesium intake and the risk of cardiovascular disease, type II diabetes and all-cause mortality; a dose response meta-analysis of prospective cohort studies. BMC Medicine 2016, 14:210
2. https://www.calmclinic.com/anxiety/drugs/magnesium
3. Urashima, M., Segawa, T., Okazaki, M. et.al. Randomized trial of Vitamin D supplementation to prevent seasonal influenza A in schoolchildren. Am. J. Clin. Nutr. 2010 May, Vol 91(5)1255 – 1260
Generalised arthritis, especially involving the lower limbs is also interesting. Radiologically, they show up as Calcium deposition in the soft (connective) tissue surrounding the joints. This inappropriate calcium deposition is associated with Vitamin D deficiency and probably bodily pH, as we tend to be too alkaline. Also, in sleep disturbances, there is random lower limb movement throught the night due to lack of proper deep sleep muscle paralysis; this is why we wake up with lots of ‘aches and pains’. This is shown by actinography. when deep sleep is restored (including with Magnesium), a lot of early morning joint pain disappears.
Hi Tad,
thanks for your comment and the reference to your paper which I will read fully. I agree with you and with Sedgewick that we need to look at how concepts emerge in relation to social practices and the structures and needs of the societies in which they are embedded. I think Foucault’s work is most useful here since he shows how what came to be regarded as psychiatry arose from social practices that emerged alongside industrial capitalism, and that the medical view of the activity was superimposed, thus obscuring the system’s social and political functions.
I think this sort of analysis reveals the issues that are embedded in our language about mental health and illness, and helps us to identify the interests and functions that are currently served by designating mental disorders as ill health. Do you not think that Karl Marx was privy to a deeper understanding of capitalism than bourgeois political economists?
Dear Duncan and Tad,
You can define mental dysfunction or loss of contact with reality or inexplicability of behaviour as illness if you want to. But if we do, we need a new concept that refers to conditions of the body specifically, because these situations have their own particular and unique implications, as I suggested in the first blog of this series, and these differ from situations in which behaviour emanates from a self-directing individual. Because we have muddied the concept of illness so much, we have, in fact, had to invent new concepts to refer to a bodily disorder – we talk of organic illness or physical illness or medical illness, and the concept of ‘disease’ also sometimes works to indicate a specifically bodily condition.
Wittgenstein’s analysis of mental states does not deny that they exist or are important, but shows how we learn to identify and understand them through the behaviour in which they are expressed. Jeff Coulter’s work on the identification of psychosis is useful here. He points out how that loss of contact with reality that you mention is expressed in behaviour that others find perplexing, frightening, alien, disconnected etc. This is the situation that is understood as madness, and it is identified not by psychiatrists or psychological experts, but by the community in which the individual lives.
However, you also raise an interesting question about whether inexplicability of behaviour suggests the presence of a brain disease – an actual material brain process like MS. Indeed I think we do have an understandable inclination to assume that if someone’s behaviour is incomprehensible, then it must be the result of some process that is external to the individual’s agency, like a biological disease process. When we exclude organic factors in someone who presents with an episode of psychosis or severe depression, this is exactly what we are thinking. However, I think there are situations in which the meaning of someone’s behaviour and utterances is difficult to fathom, but not the result of a brain process. I am going to deal with these questions more in the next few blogs, but I think they are complex and important.
Jo, I’m not arguing that ‘un-understandabilty’ suggests brain disease, but it does suggest mental illness, which is a functional term, of course dependent on a biological organism. We don’t need any new concepts, as we already have, for example, Engel’s biopsychosocial model, the implications of which are not always fully appreciated. I look foward to your further blogs!
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