Mental Illness as ‘an Illness Like Any Other’: A Critical Review
Debates over the nature of mental illness have revolved around two positions: mental illness as ‘myth’ and as ‘an illness like any other’. We argue that the debate requires a subtlety of analysis which has hitherto been lacking.
For the past fifty years, debates over the epistemological status of mental illness have revolved around two positions: mental illness as a myth (Szasz, 1960) and mental illness as an illness like any other (Albee & Joffe, 2004; Sedgwick, 1982). We briefly review the arguments of Thomas Szasz and Peter Sedgwick to situate the ‘mental illness as an illness like any other’ position in an historical context. We then consider this position in a contemporary context, distinguishing between the ‘soft’ Sedgwickian version of this argument and the ‘hard’ reductive biological version and focusing on the interplay of science, politics and ideology in this controversial debate.
Szasz and Sedgwick on Illness
The ‘mental illness as an illness like any other’ position must be understood primarily as a response to Thomas Szasz’s claim that mental illness is a myth. Szasz grounds his critique in an analysis of the term ‘illness’ and its application both to the body and to the mind. For Szasz, bodily illness is a deviation from objective, medical norms and is thus an unproblematic concept:
The concept of illness...implies deviation from a clearly defined norm. In the case of physical illness the norm is the structural and functional integrity of the human body...what health is can be stated in anatomical and physiological terms (Szasz, 1990, p.14)
On the other hand, mental illness is seen by Szasz as a deviation from social and ethical norms and ultimately as ‘problems in living’ (Szasz, 1960, p.113) and is thus a highly problematic concept when brought into the realm of medical science. He writes that the norm from which deviance is regarded as a mental illness ‘must be stated in terms of psychosocial, ethical and legal concepts’ (Szasz, 1990, p.14). Thus mental illness can only be understood as a metaphorical disease (Szasz, 2007), an example of ‘confusing what is real with what is imitation, literal meaning with metaphorical meaning, medicine with morals’ (2007, p.6).
For Sedgwick, Szasz’s key argument rests on a flawed assumption: bodily illness is not a conceptual problem (1982). He argues that the perceived difference between bodily and mental illness is in fact illusory: ‘The medical enterprise is from its inception value-loaded; it is not simply an applied biology, but a biology applied in accordance with the dictates of social interest’ (1973, p.31)
Sedgwick argues that the apparent factual and objective nature of physical illness points not to the absence of a normative framework for judging bodily pathology, but rather to values in judging bodily illness that are wide-spread to the point that we take them for granted and consider them as facts, unlike the highly contested values present in mental illness (Sedgwick, 1982).
If all illness involves value judgments, then excluding mental illness from the broader category of illness must logically ‘constitute the crudest dualism’ (Sedgwick, 1973, p.38). Thus Sedgwick advocates a unitary concept of illness in which mental illness is understood as an illness like any other.
Mental Illness as an Illness Like Any Other
The focus in Sedgwick’s account on values is crucial as it does not point to the inevitability of the reductive biological approach that is often used to support the position that mental illness is ‘an illness like any other’ or ‘just like diabetes’ (Arpaly, 2005). As Sedgwick wrote: ‘Nothing in my argument confirms the technologising of illness; the specialised medical model of illness is not the only possible one’ (1982, p.39).
It is thus possible to distinguish two versions of this position: the ‘soft’ Sedgwickian version understands mental illness as ‘just like diabetes’ due to the presence of values in both mental and bodily illness; the ‘hard’ version understands mental illness as ‘just like diabetes’ as it is seen as a disease of the brain just as diabetes is a disease of the pancreas.
Increasingly the hard version is supported by prominent mental health practitioners and academics, with the implication that this assertion is soundly rooted in the soil of science:
These are real illnesses of a real organ, the brain, just like coronary artery disease is a disease of a real organ, the heart (Steven Hyman, director of the National Institute of Mental Health, quoted in Albee & Joffe, 2004, p.419)
Schizophrenia is now generally believed to be an organic disease like diabetes or cancer (Michael Robbins, psychiatrist, quoted in Johnstone, 1999, p.120)
It is worth exploring what exactly is meant by referring to mental illness as an illness/disorder/disease of the brain, because at one level of course, the answer is ‘not much’. Assuming that a Cartesian substance dualism is not accepted, then it is of course unavoidable that mental illness is at some level a brain/biochemical state, but if this is all that is claimed then why not understand love or indeed any human thoughts or behaviour at this level (Arpaly, 2005)? It is, in short, a rather trivial statement, as trivial as suggesting that mental illness is caused by a combination of heredity and environment. Statements like these sound authoritative and rooted in science but in fact ‘obscure a number of central features of mental illness’ (Sedgwick, 1982, p.25).
One of the facts that these kinds of statements may serve to obscure is that when it comes to the far less trivial question of whether brain states play a causal role in the aetiology of mental illness, there is still no evidence that this is the case, despite advances in the neurosciences (Bentall, 2004). Arguments for the causal role of brain processes in the aetiology of mental illnesses tend to be made from the perspective of the success of medication in alleviating symptoms but these arguments are notoriously circular and do little to counter the reverse argument that prolonged suffering can cause structural abnormalities in the brain (Pilgrim, 2008).
A risk of moving towards an explanation of mental illnesses as illnesses of the brain is that it obscures the fact that psychiatry and psychology are unavoidably involved in the ‘meaningful world of human reality’ (Bracken & Thomas, 2010a, p.219). But perhaps this is the point. Before exploring this point in greater detail, it is worth considering this quote by the child psychiatrist Harold Koplewicz:
It’s hard to believe that until 20 years ago we still believed that inadequate parenting and bad childhood traumas were the cause of psychiatric illness in children. And in fact, even though we know better today, that antiquated way of thinking is still out there, so that people who wouldn’t dream of blaming parents for other types of disease, like their child’s diabetes or asthma, still embrace the notion that somehow absent fathers, working mothers, over-permissive parents are the cause of psychiatric illness in children. And the only way we can change that is through more public awareness. I mean, essentially, these are no-fault brain disorders (quoted in Albee & Joffe, 2004, p.433-434)
It is not difficult to see how this statement could be seen as rooted in ideology rather than science or even just basic common sense. In order to understand the context of Koplewicz’s statement better, a very brief historical exploration is useful. Far more than any other figure in the anti-psychiatry movement, R.D. Laing shook the foundations of society. If mental illness was demonstrably rooted at some level in the complex social dynamics of the family and thus society as a whole, then a profound challenge to traditional ways of thinking about mental illness and indeed the traditional structures of society would be unavoidable. Yet fortunately for psychiatry, Laing became progressively more disreputable, esoteric and dependent on alcohol until it became rather easy to present him as something of a quack, and more importantly to blame him for the unhappiness he caused to parents by suggesting they may have been in some way involved in the distress of their offspring. A quote like the following from the economist Lord Layard is not uncommon in its open condemnation of Laing: ‘It is difficult to forgive the unhappiness caused to parents by psychoanalysts like R.D. Laing who insisted that schizophrenia was caused solely by experience’ (2005, p.212)
Elsewhere, attempts within psychiatry to distance themselves from Laing are abundant and tend to focus, like Layard, on the harm done to the family: ‘Theories of family pathogenesis have in the past been widespread and are still held by some professionals. This has resulted in relatives being blamed and stigmatised for the patient’s illness’ (Nicholas Tarrier, quoted in Johnstone, 1999, p.120)
Yet it remains difficult to demarcate those critiques of Laing that are scientific in nature from those that are driven by more political or ideological concerns. Not only has the research into the genetics of schizophrenia and other mental illnesses upon which the attack against Laing has primarily been based been demonstrated to be so methodologically flawed that the results are practically meaningless (Joseph, 2003), but, as Johnstone has argued, any notion of the family as causing mental illness is still considered a scientific ‘taboo’ (1999, p.119), a position that is distinctly antithetical to the supposed openness of science as a mode of inquiry, especially in light of the significant body of research that supports this position (Johnstone, 1999). As Johnstone writes:
If ‘schizophrenia’ is a dramatic manifestation of some of the central contradictions of our Western industrialised way of life, filtered through family dynamics, it is not surprising that the debate surrounding it has been so controversial (1999, p.131)
In the continued emphasis on the ‘bio’ over the ‘psycho’ and ‘social’ aspects of mental illness (Read, 2005), there is an increased risk of:
If all ‘mental illnesses’ result from pathologies in the brains of those showing disturbed interpersonal (and intrapersonal) relationships, then efforts at prevention need pay little attention to the social environment in which the affected person lives and has developed (Albee & Joffe, 2004, p.434)
If then the debate over the nature of mental illness is conducted primarily at a moral or political rather than at a scientific level, one obvious moral consideration is the treatment of people with mental illness by members of the public. If the approach of thinking of mental illness as an illness like any other reduces prejudice and counters stigma, then from a moral or political perspective this may seem a reasonable approach to take. This has in fact been one of the primary motivations for taking the ‘illness like any other’ position (Cresswell & Spandler, 2009). Yet this approach, which in its simplistic, non-Sedgwickian approach to the concept of illness, endorses a ‘disease of the brain’ understanding of mental illness, has failed in its aims to reduce stigma and prejudice and in fact increased stigma and the desire for social distance (Read et al., 2006; Woods, 2011). This could have been predicted. As early as 1981, Hill and Bale wrote:
The notion that psychological problems are similar to physical ailments creates the image of some phenomenon over which afflicted individuals have no control and thereby renders their behaviour apparently unpredictable. Such a viewpoint makes the ‘mentally ill’ seem just as alien to today’s ‘normal’ populace as the witches seemed to fifteenth century Europeans (quoted in Read et al., 2006, p.311)
More recently, Fernando (2010) writes that psychiatric stigma may be extremely difficult to counteract given the popular assumption that schizophrenia ‘is a medical condition which...is associated with dangerousness, violence, confusion and, more than anything else, alienness that renders people afflicted with it being beyond understanding, irrational and bizarre; that is the way they are’ (2010, p.39). He concludes that ‘to get rid of the stigma we need to get rid of the genetic-biomedical model of mental illness’ (2010, p.39)
How Mental Illness is Not an Illness Like Any Other
In support of his frequent use of dualisms, Szasz writes that: ‘Binariness is an attribute of the natural world’ (2010, p.230) whereas Bracken and Thomas write that Szasz’s approach is ‘limited by an adherence to an ‘either/or’, ‘right/wrong’ form of analysis’ (2010b, p.244) and that ‘such distinctions often serve to give us a false sense of clarity’ (2010b, p.242). Ratcliffe, writing from a phenomenological perspective, states that ‘a contrast between ‘mental’ and ‘bodily’ is often uninformative and unhelpful’ (2010, p.235) and that ‘what phenomenological study consistently shows is that experiences of ‘mental’ and ‘bodily’ symptoms cannot be neatly separated’ (2010, p.236). He concludes by suggesting that a distinction between the bodily and the mental ‘is not an absolute distinction, but a pragmatic one’ (2010, p.238) based on whether mental or non-mental symptoms are experienced as most troubling to the individual.
It is worth exploring in greater depth this interplay between body and mind in mental illness. Arpaly argues that it is crucial to distinguish mental states from brain states:
If computers are completely physical, and yet one can meaningfully distinguish hardware and software problems, then it is possible that though humans are completely biochemical, one can still tell mental states and problems from non-mental biochemical states and problems (2005, p.283)
She then asks us to consider the case of anxiety induced by drinking caffeine as opposed to anxiety induced by the prospect of losing one’s job (2005, p.286). While one may suggest that the former example is ‘just like diabetes’ while the latter example is not, this cannot be because the former is biological and the other non-biological. As Arpaly writes: ‘Humans are biological entities, anxiety is in the brain, so presumably all anxiety is biological’ (2005, p.286)
The challenge for any account of mental illness must be to distinguish between mental states that are ‘just like diabetes’ (i.e. anxiety induced by drinking caffeine) and those that are more ‘purely’ mental in the sense that they are meaningful and responsive to events in the world (i.e. anxiety induced by the prospect of losing one’s job). Yet this distinction has a complexity that is beyond the scope of positions like Szasz’s: ‘It can sometimes be very, very hard to tell apart the roles of rational factors, non-rational but meaningful factors, and meaningless, "hardware" factors when explaining mental states’ (Arpaly, 2005, p.288)
Consider Louis Sass’s account of patients with schizophrenia (Sass, 1992). While dismissing the notion that schizophrenic states are entirely under the patient’s control as ‘absurd’ (1992, p.73), he criticises the overly simplistic understanding of schizophrenic states as ‘resulting from a simple loss or diminishment of self-control’ (1992, p.73) and describes some examples of patients who seem to bring on schizophrenic states through an act of will (1992, p.72-73). He writes that ‘so much about schizophrenia...is difficult to characterize in our standard vocabulary of volition and determinism; it seems to occupy a kind of anxious twilight zone somewhere between act and affliction’ (1992, p.73-74)
Pearce and Pickard (2010) ask us to consider someone who starts withdrawing socially, spending less time on their personal hygiene and finding it increasingly difficult to go to work. A parent or a partner may consider this behaviour self-indulgent and irresponsible but once a depression diagnosis has been obtained from a doctor, the behaviour is then seen as symptomatic – to be understood as ‘effects of the depression, a condition that has befallen them, as opposed to expressions of their own choices and will’ (2010, p.831). But they suggest that this view is mistaken and that in the case of depression or addictions, for example, the very actions and omissions that constitute the key ‘symptoms’ are in fact within the patient’s control, however difficult they may be to control (2010, p.831). They argue that mental health professionals do not help their patients by assuming that ‘they are in a sense beyond help’ (2010, p.832).
In line with this position, Dalrymple (2010) questions whether we in fact turn patients ‘into something less than a man [sic]’ (2010, p.43) by excusing them from standard moral expectations because of their mental illness. Similarly Arpaly (2005) points out that if a woman treats her depressed husband as akin to a diabetic, as someone who is the victim of a disease and thus helpless and impotent, in ‘treating his suffering [in this way] she misunderstands [the condition] and aggravates it’ (2005, p.297), while Schoeman (1994) suggests that our thinking about what is fair to expect of people with mental health problems ‘must respect the ambiguities implicit in our understanding of what individuals can do’ (1994, p.195)
Issues surrounding agency and responsibility in mental illness are of course very contentious and there is plenty of evidence to suggest the exact opposite of the positions stated above, especially in more severe cases (Hornstein, 2009). But while thinkers like Arpaly (2005) and Pearce and Pickard (2010) tend to emphasise the ambiguities and uncertainties inherent in any exploration of agency and moral responsibility in mental illness, there is no such ambiguity in Szasz’s account and it seems reasonable to take him to task for his failures of basic human empathy. For in seeing people with mental health problems as essentially liars who can use an act of will to make their symptoms go away, it could be argued that his position actually precipitates the need for the sufferer to obtain an illness label simply in order to convince those around them that their suffering is not simply ‘some childish charade that can be stopped with a little good old American effort’ (Arpaly, 2005, p.296). Bracken and Thomas write that Szasz’s position ‘misrepresents the reality of [patients’] suffering’ (2010a, p.223) and that ‘a great deal of human suffering demands that we think beyond binaries’ (2010a, p.223). We can thus reject both the Szaszian position and the hard version of the ‘illness like any other’ position as inadequate for dealing with the complex, ambiguous and often paradoxical nature of mental illness.
The hard version of the ‘mental illness is an illness like any other’ position is fast becoming an orthodox one within the mental health system and this has little to do with its grounding in science. As Sedgwick’s soft version is increasingly replaced with this reductive biological understanding of mental illness, his emphasis on the unavoidability of values in all illness retains its crucial role in the debate. Without the subtlety of Sedgwick’s analysis, the position that ‘mental illness is an illness like any other’ becomes little more than an empty slogan serving ideological goals, no different in kind from Szasz’s slogan that ‘mental illness is a myth’.
Mental illness is neither a myth nor is it an illness like any other in anything more than the modest Sedwickian sense. Perhaps it is best thought of as a ‘mystery’ (Kelly et al., 2010, p.38). Before attempting to foreclose debates on the epistemological status of mental illness, it is worth keeping in mind that, as Ratcliffe points out, we are still left with the question of ‘what it is that makes something an ‘illness’’ (2010, p.239). As it stands, how we define illness, let alone mental illness, still remains at the level of decision rather than analysis (Pickard, 2009). Until we know what we mean by illness, the position that mental illness is ‘an illness like any other’ will continue to ring rather hollow.
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Anthony Morgan lectures in the history and philosophy of psychology at Northumbria University and runs mental health and philosophy groups in Newcastle-upon-Tyne.