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Are Mental Diseases Particularly Problematic?

Often it has been thought that mental disease is more problematic than bodily disease. As my account treats mental and bodily disease together I am under some pressure to provide reasons whydeciding whether someone suffers from a mental disease might appear particularly difficult.

I suggest that questions concerning mental disease are especially frequent for rather mundane practical reasons. We debate whether someone suffers from amental disease more often than whether someone suffers from a bodily disease because suffering from a mental disease carries heavier social and legalconsequences within our society. The existence of the insanity defence, and ofcompulsory treatment orders, and the stigma attached to mental disease, all make itmore important to decide whether or not someone suffers from a mental disease.

In addition, problems linked to deciding whether or not someone suffers from a mental disease have received far more publicity than those linked to deciding whether or not some one suffers from a bodily disease. R.D.Laing, Thomas Szasz, Michel Foucault,and other influential authors chose to write about mental and not bodily disease. The emphasis of public debate is now perhaps beginning to shift; debates as to whether deaf children should be given cochlear implants, which are often in effect debates concerning the disease-status of deafness, have recently received widespread media attention.78 I suspect that deciding whether someone suffers from a bodily diseasecan be just as problematic as deciding whether they suffer from a mental disease.Having said this, I should point out that it is not an integral part of my account ofdisease and I shall now outline how my account of disease is compatible withFoucault’s and Laing’s accounts of mental disease. I do not wish to commit myselfto accepting these accounts, but they have been influential and so it is worth pointingout that they are compatible with my own. If acceptable, any of these accountswould explain why mental disease is more problematic than physical disease.

In Madness and Civilisation (1961 as Histoire de la Folie,1967 in English)Foucault argued that contemporary notions of mental illness are rooted incontingent, historical developments. According to Foucault, prior to theEnlightenment the mad were tolerated and seen primarily as different, and possiblygifted, rather than as ill. The Enlightenment idolisation of reason then renderedsociety newly incapable of coping with the “unreasonable” in its midst, and sovagabonds, delinquents, and the mad came to be shut away in huge institutions.

Of this mixed group, the mad alone were unable to fit into institutional life and so,through forming a residual problem population, became visible as a group for thefirst time. Following various inter-professional power struggles, the medical profession eventually gained authority over this group, who came to form “thementally ill” as we know them today. If Foucault is right, then the mad have notalways been seen as suffering from mental diseases. The reasons Foucault cites -that madness was not always seen as a bad thing, and that madness was not thoughtof as being a medical problem – are precisely the kinds of reasons that my accountsuggests should lead us to think of a condition as a non-disease. Thus his account iscompatible with my own.

My account is also compatible with Laing’s accounts of schizophrenia. Laingdeveloped two completely different and influential accounts of schizophrenia duringhis career. First, with A.Esterson in Sanity, Madness and the Family (1964) hedeveloped an account according to which, rather than there being something wrongwith schizophrenics as individuals, there is something wrong with their families.According to Laing and Esterson the families of schizophrenics present them withconfused and impossible demands. The schizophrenic in the family tries to make thebest sense possible of an insane situation. Still, since you can’t make a silk purse outof a pig’s ear, the best sense possible isn’t very good and so the schizophrenic endsup appearing to be insane. This account can be glossed as claiming thatschizophrenics are not suffering from a disease because they do not require medicaltreatment – there isn’t actually anything wrong with them as individuals. Again, thisis the kind of reason that my account suggests should lead us to think of a conditionas a non-disease.

Later, in The Politics of Experience (1967) Laing developed an accountaccording to which schizophrenia is a mystical journey to a higher form of sanity.According to this account it is us “normals” who are truly alienated from ourselves.From childhood on we have been conditioned, first by our family, then at school,then at work, to act in ways that do not conform with our experiences, for example we are trained to be polite to people who offend us. Under such pressures we createa false-self to present to the world. Schizophrenics are people who have refused toconstruct a false-self and as such are better off than the rest of us. Their experiences are part of a healing spiritual journey that can potentially lead them away from normality and into a higher form of sanity. This account is also compatible with myown. Laing can be understood as claiming that schizophrenia is not a disease because it is not a bad thing and, if this were so, I would be forced to agree withhim.

My account is not compatible with Thomas Szasz’s account of mental illness. Ina series of influential publications, spanning from the 1960s to the present day,Szsaz has argued that mental diseases do not exist.79 According to Szasz, talk of sickminds is merely metaphorical, in the same way as is talk of sick economies. Szaszclaims that someone can only be said to have a disease, in the literal sense, if thisdisease is caused by some physical abnormality. Claiming that someone has amental disease is taken to imply that they literally have a disease but that this diseasehas no physical basis. Thus Szasz concludes, while there may be brain diseases,there can be no mental diseases.

Szasz promotes his ideas as if they are extremely radical. His slogan that mentalillness is a “myth” implies that psychiatrists are charlatans and/or agents of socialcontrol and, not surprisingly, psychiatrists have often been insulted by this. Still, I think that on the most plausible reading Szasz’s claims turn out to be fairly moderate, and the disagreement between his account and my own will be slighterthan might have been expected. Szasz accepts that if schizophrenia, depression,autism, and so on turn out to have some physical basis then they are real diseases.He just chooses to refer to any real diseases that have psychological symptoms asbrain diseases rather than as mental diseases. As there is increasing evidence that agreat many of the conditions that psychiatrists treat have some kind of physical basis, this means that Szasz will have to accept that much of the time psychiatrists treat real diseases.

Much of Szasz’s anger has been directed at those who have claimed that what he thinks of as being symptoms of social discord, such as war, crime, and relationship problems, are in fact symptoms of mental illness. Such attempts to put medicine inthe place of politics and ethics are dangerous, Szasz thinks, because their implicitdenial of the importance of individual responsibility and of free-will isdehumanising. Here I can agree with Szasz. On my account social problems andproblems in living are not diseases either, because they are not appropriately medically treated.

The only remaining disagreement between myself and Szasz concerns the possibility that some genuine diseases might have no biological basis. Szasz claims that all real diseases have a physical basis; I claim that it is conceivable that some diseases do not. For example, I think that quite possibly we will never be able to distinguish phobias from rational fears by looking at someone’s brain, but that phobias can still be diseases.

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