response to Joanna Moncrieff

Joanna Moncrieff recently posted a response to chapter 1 of my book On Madness on her blog. I'm grateful to her for taking the time to read and engage with it. Here in turn is my response.

As Joanna notes, I don't myself believe that the use of medical terms - like "ill health", "unwell", "illness", and the sometimes medical "disorder" - when these are prefixed with "mental" or "mentally" or "psychological" - by itself implies that there's something wrong with the person's body (including their brain). There may of course sometimes be something wrong with the person's body - e.g. with their central nervous or endocrine system - which causes the mental illness. However that's a claim about efficient causes - about what instigates some particular mental illness; it's not a claim about what mental illness is. 

I'd even say that properly trained psychiatrists make a distinction between mental illness and brain disease such that diagnosing the latter excludes the former (in a way I elaborate later). And I guess it is, in a sense, trivially or analytically true that mental illness involves disturbance of brain function - but that's just because: the concept of a "brain" is the concept of the organ dedicated to sensorimotor functions and their rational elaborations and because paradigmatic mental illness involves a certain kind of rational disturbance (in 'reality contact' and 'reality testing'). But again that's just trivial, and in no way implies that we can identify or individuate mental illnesses by looking at brains. What goes on in the brain - in terms of typical or atypical neurological activity identified merely by reference to what happens inside the head - is no part of the concept of mental illness.

Finally, structural brain problems, neurological disease and injury, can sometimes give rise to the disturbances of brain function that are found in mental illness. But to have neurosyphilis or whatever is in no way to ipso facto have a mental illness. (Here "mental disorder" and "mental illness" part ways; the former concept being a disjunctive amalgam of mental illness and brain disease.)

About much of that, Joanna and I no doubt agree. But not about the fundamental idea, perhaps owed to Thomas Szasz, who felt that references to illness, even in the concept of "mental illness", were somehow unsound unless they entailed a brain (or more general bodily) disturbance of a non-trivial (in my above-outlined analytic sense) sort - in which case they're misleading because that's neither what we find in mental illness nor how mental illnesses are diagnosed. But then - I wonder - what of the fact that we talk of a country or society being sick, of social ills, of an ailing economy; of moral sickness or spiritual disease; of love sickness, toxic masculinity, a poisoned atmosphere, a dying relationship, the pathology of extremism, computer viruses, anti-virus software, a computer becoming infected, etc? In these cases, it seems, we're to accept the metaphorical nature of the illness. None of such talk makes of the sociologist, economist, politician or computer technician a conceptual blunderbuss. None of it induces the terms' users to think there's something wrong with the insides of the sufferer of lovesickness, that we ought to give anti-nausea medication to the homesick, or that she whose computer has a virus would do well to book it a GP appointment.

I take it that this is all uncontroversial. An autistic person who struggled with symbolism and conceptual metaphor might perhaps become perplexed, but ordinarily we find no trouble here at all. So what I don't understand is why in the case of "mental illnesses" the very concept is taken to lead us up the garden path or to be rooted in what Joanna calls a "misconception". She and I agree that medics have, buoyed on by only a handful of actual results (neurosyphilis, the dementias, Huntingdon's, epilepsy, Wilson's disease, etc) and perhaps by their general training - in internal medicine after all - spent far too much time and money pursuing neo-Kraepelinian research agendas in the hope of finding subtle brain diseases as the causes of mental disorders such as bipolar and schizophrenia. We'll doubtless also agree that those with mental illnesses are often given medicaments (e.g. depressives are given so-called "anti-depressants" by their GPs who perhaps have little else to offer). All of that suggests that many medics may very well indeed be up the garden path. But whether it's their concepts, or instead their medical bent, their hopes for money or fame or an easy medicinal fix, or their desperation that led them there is quite another matter.

A patient (I'll disguise the details) said to me just this week: "When I fall prey to this damn OCD I'm really ill". "What do you mean by "ill"?" I asked. "I mean I'm just really not myself, I feel dreadful, and my mind's just not working right". This talk of "illness" was spontaneous. Yes, she went on to seek medicinal help to "calm her nerves". No, it didn't occur to her, or me, or her GP, to think that any of this meant that psychotherapy was contraindicated. Why? Well, why would it?! (The medicine's effects was effectively understood in what Joanna calls "drug-centred" terms: it was used for its helpful effects, and it helped her to become less (metaphorically) ill, i.e. less mentally troubled.)

In her substack Joanna suggests that most people now use the term "mental illness" to mean a disease of the brain. In relation to how psychiatrists in particular use it, she cites some research she did on what topics psychiatrists tended to publish on in the British Journal of Psychiatry throughout the 20th century. Here she found that their publications on basic biological sciences, genetics, psychopharmacology, physical treatments, etc vastly outnumbered those on psychotherapy, social sciences, and psychoanalysis. 

I find myself wondering what this data really shows. The BJP was originally an asylum journal, and the doctors involved in the asylums had, at least earlier in the 20th century, large caseloads of organically impaired patients (neurosyphilis, epilepsy, dementias, microcephaly, etc), along with hysterics and general deviants, and with their medical background naturally had an interest in the organic aspect of their patients' struggles. And if we look to the American Journal of Psychiatry - another asylum journal by the way - for comparison, we find that by the 1940s and up to the 1960s there are lots of psychologically-oriented pieces. (In the issue I just picked at random (December 1955) the set of papers is comprised of 'Man and human nature'; 'Neurosis and the Mexican family structure'; 'The development of play as a form of therapy'; 'Some psychiatric considerations regarding creative writing and criticism'; 'Psychological services for chronic mental patients'; 'Supervision in psychotherapy of schizophrenia'; 'Verification of the Rorscharch Alpha Diagnostic formula for underactive schizophrenics'; 'The selection of psychiatric aides'; 'Psychological effects of cortisone in acute catatonia'; 'The psychodynamics of the 'dry drunk'; 'Hernia striangulation as a side effect of ECT'; 'Concerning theories of indoles in schizophrenogenesis'.) 

Psychological themes them receded in the post DSM-III era, to be largely replaced by the kinds of concerns Joanna found in the BJP, with (in the issues I randomly sampled) a smattering of papers on the effects of trauma on later psychopathology and on the brain, on the value of psychotherapy for depression etc. But, again, what of any of this? It provides no evidence of a change in the concept of mental illness, no evidence that what people mean by "mental illness" is a neurological disorder. (The criteria for being mentally ill operate at an entirely different juncture - i.e. in particular disturbances of rationality etc.) It - the shift in concerns - instead largely reflects changes in what people think causes mental illness.

That distinction - between i) efficient or ii) material and iii) formal causality, if you like, or instead between questions about iii) its essence, about the rules of engagement for the term "mental illness", and questions about ii) its material realisation in brain (and rest of the body) and i) its distal and proximal precipitants ("causes" as we typically use the term today) - is fundamental to the approach to the iii) analysis of the concept I take in my book. There I noted that it's perfectly possible to espouse the view that a certain mental illness is caused by a structural neurological disturbance and realised in a functional neurological disturbance without itself being a neurological disorder. Why? Because the logical criteria for its identity - the rules for the proper use of the term - show it to be of a different sort. Now, our concepts can of course change over time, and if a mental illness turns out to have a significant and consistent subtle structural biological cause we may want to change that concept so that it's now defined in terms of its cause. This doesn't of course mean it's helpful or perspicuous to say things like "it was all along a brain disorder". What it means is that we've changed the concept so that the term in question which used to mean a mental illness now means a neurological disorder. 

In her piece, Joanna writes that for me, "the situation [i.e. the mental illness] is not explained by a brain disease". If by "explain" she means "causally explain", then she's wrong. I've no philosophical argument against those who think that the development and form taken by various mental illnesses (e.g. the schizophrenias) may best be causally explained in terms of altered brain function precipitated by subtle neurodevelopmental abnormalities (which aren't themselves merely the material cause of psychologically intelligible developmental problems). That's an empirical matter on which I'm not qualified to pronounce. I see no definitive reason to suppose that the disturbances of brain function that (again, in the trivial analytic sense) are met with in various mental illnesses must have internal (efficient) causes. But enough about me! The main point is just that there's no clear reason to infer from what scientific theories psychiatrists espouse about mental illnesses' causes to the character of the concept. Frankly, even if we asked them about the meaning of the term "major depressive disorder" and they said "it's a brain disease", I'd not be all that impressed. Ask most everyone about the meaning of various things (what does "time" mean? what is "matter"? "what does "consciousness" mean? to what does "I" refer?) and they'll talk utter rot. (Often a rather fashionable rot.) How do we know its rot? Because if we look instead at the rules for the use of the term, the rules immanent within those same people's discourse, governing it there, dictating what they will and won't count as correct uses of the term in practice, then we'll find these rules don't cohere with their explicit pronouncements about the terms' meaning. (Philosophy - gaining true reflective clarity about one's concepts - is after all a very hard business!)

A final comment on a different matter. Joanna disagrees with me that suffering is essential to mental illness. She suggests it i) doesn't make sense to say that suffering can occur without awareness, that ii) some people's chronic psychotic state enables them to avoid suffering, and iii) that if deploying a defence mechanism merely disguises rather than deactivates someone's suffering then (implausibly) we're all suffering much of the time. ("Don’t we all have ways of coping with failure, disappointment and anxiety, and when those coping mechanisms work effectively and we get on with our lives (in one fashion or another), should we consider that we are still suffering?")

Now we can of course use "suffering" in this way if we choose - making current pain or distress essential to it. And the OED does give us a significant sense of "suffer" which highlights something "painful, distressing, or injurious" being "inflicted or imposed upon one". But there are other uses of "suffer" which don't necessarily invoke distress. The general category (I.) within which that sense (I.i) is located has to do more generally with undergoing and enduring, and there are other use that speak more to tolerating or allowing (Jesus invites his listeners to suffer the little children and forbid them not to come unto me). We can suffer (a blow to our reputation, say) even after death. It's confusing but not incoherent to say "thankfully he didn't suffer when he suffered death". Someone who has spent many years alone and then finds love again may say "I now see how painfully lonely I actually was during all that time". Someone may come out of their mania or their delusion and now feel utterly anguished or ashamed. Not, or not only, by what they take to be the indignity in having collapsed as they did, but rather because they're now back in touch with the wretchedness of their life that their delusion or mania had helped them evade. At the end of the day I don't think it matters whether we say the manic or "happily" delusional patient is unconsciously suffering, whether what they were suffering was in some sense "present all along" - or whether we instead say that the conceptual link between "illness" and "suffering" relates to past suffering which the mental illness evades and which recovery restores. What matters is that we don't lose sight of the ways in which illnesses of the mind essentially arise in the midst of reality contact that has, for whatever endogenous or exogenous cause, become intolerable.