Wednesday, 29 April 2015

Another draft nursing textbook chapter

By its very nature, mental healthcare raises a number of key conceptual questions calling for philosophical, rather than empirical, inquiry. This chapter outlines some of the answers that have been proposed to, perhaps, the most central question: what is a mental illness? We then discuss links between answers to this question and concerns about the justification of coercion in mental healthcare, shared decisions about recovery, and the objectivity, or otherwise, of psychiatric taxonomy.

Mental illness and mental healthcare raise a number of difficult and deep questions. Here are just a few.
·         What is the difference between just being different and having a mental illness?
·         What, if anything, is the justification for detaining people merely because they have a particular kind of illness?
·         Should someone with a mental illness have less say over the nature of their recovery than someone with a physical illness?
·         Can a classification or taxonomy of mental illness, such as the recently published DSM-5, aspire to be as objective as the Periodic Table in chemistry. Or is it more like the Top 40?
Questions such as these seem to arise not just from quirky or accidental features of healthcare in this particular country at this particular time but from something deeper and more general: the very idea of mental health and illness. If that is so, they cannot be answered by empirical means - experiments, questionnaires etc - because such means presuppose that we already know what we mean by ‘mental health’ and ‘mental illness’. Thus trying to answer questions like these calls for a method based on examining our concepts. That method is philosophy. So in thinking about questions such as these, we are researching the philosophy of mental healthcare.
In this chapter, we will examine some recent attempts to answer the first question, starting with Thomas Szasz' suggestion that the answer is ‘nothing’ because there is no such thing as mental illness. We will then trace some connections between accounts of mental illness and answers to the other questions set out above.

Szasz and the myth of mental illness
Thomas Szasz’ attack on the very idea of mental illness is often thought of as belonging to a wider movement, called ‘Anti-Psychiatry’, which began in the 1960s, questioning the legitimacy of psychiatry. Other thinkers grouped under the same label include the French philosophical historian Michel Foucault, who argued that mental healthcare was a form of social control developed to support capitalism, and the radical British psychiatrist RD Laing. In fact, Szasz rejected the label ‘anti-psychiatry’ as firmly as he rejected the idea of mental illness.
The centrepiece of Szasz’ critique is an article and then a book called ‘The Myth of Mental Illness’. A key argument is expressed in this passage:
The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm, deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm may be, we can be certain of only one thing: namely, that it must be stated in terms of psychological, ethical, and legal concepts…
[W]hen one speaks of mental illness, the norm from which deviation is measured is a psychosocial and ethical standard. Yet the remedy is sought in terms of medical measures that – it is hoped and assumed – are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another… [Szasz 1972: 15]
The argument here starts from the assumption that mental and physical illness involve deviations from different norms. Medical intervention, however, is capable of addressing only one sort of deviation – that of physical illness – and thus it cannot address the kind of deviation from a norm implicit in mental illness. Since the conception of mental illness involves the idea that it can be so treated, there is something incoherent about the very idea.
Since medical interventions are designed to remedy only medical problems, it is logically absurd to expect that they will help solve problems whose very existence have been defined and established on non-medical grounds. [ibid: 17]
Szasz also develops a shorter argument. If mental illness is a deviation from a psychosocial norm then this leads by itself to an objection of circularity:
Clearly, this is faulty reasoning, for it makes the abstraction ‘mental illness’ into a cause of, even though this abstraction was originally created to serve only as a shorthand expression for, certain types of human behaviour. [ibid: 15]
Critical thinking stop point: think about both these arguments. Are they successful in implying that mental illness could not exist? It might help to summarise them on the back of an envelope. How might one challenge them?
Neither of Szasz’ arguments is compelling. Consider the argument of circularity. We can set it out in logical steps as follows:
1.       Mental illness is an abstraction from a description of deviant behaviour. It is defined in terms of behaviour.
2.       Mental illness is supposed to be a cause of deviant behaviour.
3.       Nothing can cause itself.
4.       So there is no such thing as mental illness.
The argument is driven by a tension between the claims in the first two premises. But on reflection, there is a natural view of mental illness that captures what seems right about the first premiss without leading to the tension with the second. We can concede that mental illnesses are identified via someone’s behaviour (for example, what they say and do) without thinking that the illness is the behaviour. It may be that the illness is the cause of the deviation such that, even though it is picked out by its characteristic effects, it is not identical to them.
Here is an example of this sort of reasoning from a different and clearer context. Lee Harvey Oswald’s action of pulling the trigger on 22nd November 1963 may be described as his mudering president John F Kennedy, the action of the moment described by its slightly later effect. The action of pulling the trigger thus both caused the death of the president but is also labelled using that later event. But no defence lawyer could have argued that, because nothing can cause itself, there could be no such act. If the analogy holds then Szasz’ argument fails. To succeed he would need some independent reason to rule out the idea that the idea of a mental illness is the idea of something that causes characteristic behaviour.
The same objection applies, also, to the argument from different norms. Just because mental illness is identified via divergence from psychological, ethical, and legal norms does not rule out the idea that it comprises some underlying biological cause of such divergence and hence might be subject to medical treatment thus undermining Szasz’ argument.
Despite these objections, however, it may seem that such a defence of mental illness concedes too much in conceding that it is a defined in essentially value-laden terms. After all, that alone suggests that mental illness status cannot be objective. Hence it is worth briefly examining two responses from Christopher Boorse and Robert Kendell which challenged just this point.

Kendell, Boorse and value-free accounts of mental illness
Like Thomas Szasz, RE Kendell was a Professor of Psychiatry but unlike Szasz, he was an establishment figure becoming Chief Medical Officer for Scotland and President of the Royal College of Psychiatrists in the UK. In ‘The concept of disease and its implications for psychiatry’ he argues in defence of mental illness or disease by suggesting a method for assessing the status of mental illness:
before we can begin to decide whether mental illnesses are legitimately so called we have first to agree on an adequate definition of illness; to decide if you like what is the defining characteristic or the hallmark of disease. [Kendell 1975a: 306]
Reviewing the history of the debate he comments:
By 1960 the ‘lesion’ concept of disease, and its associated assumptions of a single cause and a qualitative difference between sickness and health had been discredited beyond redemption, but nothing had yet been put in its place. It was clear, though, that its successor would have to be based on a statistical model. [ibid: 309]
But, as Kendell goes on to say, whilst a statistical model may address some of the weaknesses of a single lesion model, statistical abnormality by itself cannot distinguish between ‘deviations from the norm which are harmful, like hypertension, those which are neutral, like great height, and those which are positively beneficial, like superior intelligence’ [ibid: 309]. It cannot distinguish disease from mere difference. Some further criterion is needed to address the fact that illness is a specific kind of deviation from the norm.
Kendell’s preferred solution is based on the work of the British chest physician, JG Scadding.
Scadding was the first to recognise the need for a criterion distinguishing between disease and other deviations from the norm that were not matters for medical concern, and suggested that the crucial issue was whether or not the abnormality placed the individual at a ‘biological disadvantage’... He defines illness not by its antecedents – the aetiological agent or the lesion producing the overt manifestations – but by its consequences. [ibid: 309]
Kendell goes on to argue that ‘biological disadvantage’ must involve increased mortality and reduced fertility, ‘whether it should embrace other impairments as well is less obvious’ [ibid: 310]. Thus he uses this criterion to test the idea of mental illness. Do they produce biological disadvantage by reducing fertility or life expectancy? After some investigation – which turns on empirical facts about the effects of these putative illnesses – he is able to come to a modest, positive conclusion.
Schizophrenia, manic depressive illness, and also some sexual disorders and some forms of drug dependence, carry with them an intrinsic biological disadvantage, and on these grounds are justifiably regarded as illness; but it is not clear whether the same is true of neurotic illness and the ill-defined territory of personality disorder. [ibid: 315]
Two things are worth noting about Kendell’s approach.
  1. His criterion of illness is general. It applies to physical and mental illness. Any condition is an illness if it leads to biological disadvantage of the right sort. That said, it is originally derived from considerations of paradigmatic physical illnesses.
  2. The criterion is purely factual and value-free. It is a matter simply of empirical fact whether a condition increases mortality and reduces fertility. If it does, then it is an illness. If not, then not.
Kendell’s approach faces a dilemma, however. On the one hand, there is ambiguity about what ‘biological disadvantage’ means. Without some further specification, it will not shed light on the nature of mental illness. But on the other, attempting to solve that problem by appeal to the idea of increased mortality and reduced fertility produces a theory of illness or disease which is vulnerable to the objection that it does not articulate what is essential to the idea of all illnesses. Roughly speaking, it seems plausible that one might be genuinely ill without this leading to increased mortality and reduced fertility. Whilst those measures might well address illnesses which, specifically, are life-threatening and undermine reproductive ability, neither risk seems to be an essential feature of everything that we might call ‘illness’ or ‘disease’.
At the same time, the US philosopher Christopher Boorse also attempted to articulate a value-free, purely descriptive account of disease – which he contrasts with illness, although we will ignore that distinction here – but using a conceptually richer notion: biological function. In ‘On the Distinction between Disease and Illness’ Boorse claims that:
The state of an organism is theoretically healthy, i.e. free of disease, insofar as its mode of functioning conforms to the natural design of that kind of organism… the single unifying property of all recognized diseases of plants and animals appears to be this: that they interfere with one or more functions typically performed within members of the species. [Boorse 1975: 57]
More precisely the theory runs:
An organism is healthy at any moment in proportion as it is not diseased; and a disease is a type of internal state of the organism which:
i)             interferes with the performance of some natural function—ie some species-typical contribution to survival and reproduction—characteristic of the organism’s age
ii)            is not simply in the nature of the species, ie is either atypical of the species, or, if typical, mainly due to environmental causes.
[Boorse 1998: 108]
Like Kendell, Boorse suggests that there is more to being diseased than being different. His is not a merely statistical approach. Instead, the sense that there is something wrong about having a disease is captured by the idea that it threatens natural biological functions. But whilst there is a connection between such functions and the contribution they make to an organism’s overall fitness, not every such failure of function need be directly correlated with actual increased mortality and reduced fertility. Biological function is thus a more fine grained approach to the concept disease or illness that Kendell’s appeal to biological disadvantage.
Critical thinking stop point: think about the idea that illness or disease is a failure of biological function. Is this a good definition? Are there any illness that are not such failures and are there any failures that are not illnesses? How well does the idea apply to mental illness?
There are two main difficulties with Boorse’s approach. The first is that failure of biological function seems more widespread than disease. In other words, not every failure of function deserves to be called a disease. For example, the function of sperm is surely to fertilise an egg. That function explains why sperm production continues in populations. But very little sperm actually does this. The benefit is so great that widespread failure can be accommodated without any implication of disease. To cope with this problem, Jerome Wakefield has proposed more recently that disease be restricted to the harmful failures of function. His approach combines biological function and dysfunction with the value: harm [Wakefield 1999]. Although his is perhaps the most famous contemporary account, it faces the second of the objections to Boorse.
The second problem concerns the application of the idea of function and dysfunctions to mental phenomena: to thoughts and experiences. It seems relatively straightforward to describe the function of the eye, for example, but rather less clear what the function is of the profound sadness of bereavement or even whether it is functional – since it is widespread – or the dysfunctional consequence of emotional bonds that are elsewhere functional (see the critical thinking box at the end). In such cases it may be that our assumptions about what is and is not mental illness drives our assumptions about mental functions rather than the other way round. If so, the account does not shed light on what we mean by ‘illness’ or disease’.

Fulford and value-laden accounts of mental illness
So far we have contrasted Szasz’ claim that mental illness is value-laden and Kendell’s and Boorse’s claims that it is value-free. How can we referee their dispute? A useful perspective is provided by the psychiatrist and philosopher Bill Fulford. The significant feature of the debate, he argues, is not so much on what they explicitly disagree but on what they implicitly agree and disagree. Once this is highlighted, a different conclusion can be drawn. Taking Szasz and Kendell to represent the poles of the debate, Fulford argues that:
Both authors assume that mental illness is the target problem: Szasz wants to ‘raise the question, is there such a thing as mental illness’? Kendell, similarly, seeks to ‘decide whether mental illnesses are legitimately so-called’. Both then turn to the concept of physical illness, acknowledging certain difficulties of definition, but suggesting criteria which they take to be self-evidently essential to its meaning: Szasz’ criterion is ‘deviation from the clearly defined norms of the structural and functional integrity of the body’. Kendell’s is ‘biological disadvantage, which must embrace both increased mortality and reduced fertility’. Finally, both return to mental illness. Szasz points out that for mental illness, the relevant norms of bodily structure and functioning are not available: on the contrary, he argues, the norms of mental illness are ‘ethical, legal and social’. Kendell, on the other hand, draws on epidemiological and statistical data to show that many mental illnesses are biologically disadvantageous in his sense, being associated with reduced life and / or reproductive expectations. Hence by Szasz’ criteria of physical illness, mental illness is a myth, whereas by Kendell’s it is not. [Fulford 1999a: 169]
According to Fulford, Szasz and Kendell both agree that mental illness is conceptually difficult and, by contrast, physical illness is straight-forward in part because the latter is value-free. From this they deduce value-free criteria for illness and apply them to mental illness with different results. As described above, Szasz argues that supposed mental illnesses are deviations from value-laden norms and thus do not meet the value-free criteria for illness. Kendell argues that they do fit his preferred criteria of increased mortality and decreased fertility.
Fulford argues, however, that the assumption that Szasz and Kendell, and Boorse for that matter, share is wrong. Physical illness is not value-free. It merely seems that way because we tend to agree on the values that underpin physical health and illness whilst there is much more variation in the values governing mental health and illness. Further, it is a general feature of value judgements that when we agree on underlying values they can become disguised by value-free criteria.

What’s the evidence? RM Hare on value terms
Fulford’s account of value terms draws on the work of philosophers such as RM Hare (1919-2002) and JL Austin (1911-1960), writing particularly in the middle decades of the 20th century, in the ‘Oxford school’ of linguistic analytic philosophy. In his Language of Morals, Hare discusses the logical properties of value terms [Hare 1952].
The value judgments expressed by (or implicit in) value terms are made on the basis of criteria that, in themselves, are descriptive (or factual) in nature. The value judgment expressed by ‘this is a good strawberry’, in one of Hare’s examples, is made on the basis that the strawberry in question is, as a matter of fact, ‘sweet, grub-free’. Hare points out that where the descriptive criteria for a given value judgment are widely agreed, the descriptive criteria that may come to dominate the use of the value term as a consequence of repeated association. In the case of strawberries, most people in most contexts prefer or value strawberries that are sweet and grub-free. Hence the use of ‘good strawberry’ comes to be associated with descriptions such as ‘sweet, grub-free, etc’. This contrasts with, say, pictures where there are no settled descriptive criteria for a good picture because there is no general agreement about pictorial aesthetics.
Hare’s general conclusion is this: value terms by which shared values are expressed may come, by a process of simple association, to look like descriptive (or factual) terms, whereas value terms expressing values over which there is disagreement, remain overtly value-laden in use.
Fulford argues that the same contrast applies to mental and physical illness. It is because mental healthcare is concerned with areas of human experience and behaviour, such as emotion, desire, volition, and belief, where people’s values are particularly highly diverse that it seems more value-laden than physical illness.
Fulford’s positive account of the nature of illness draws on the idea of ordinary doing as the kind of action that one ‘gets on and does’ without having to try, without having intentions explicitly in mind [Austin 1957]. A failure to be able to do this kind of thing, in the absence of external constraint, captures, Fulford argues, the character of experiences of illness. As a hypothesis, moreover, it helps to explain a number of the key features of medicine. In particular, the idea that illness comprises an internally generated failure of ordinary doing explains its values-ladenness because the ineliminable concept of failure of ordinary doing itself suggests an ineliminable negative value judgement.
This is true of physical illness as well as of mental illness but because there is much more agreement about the sorts of things we should be able physically or bodily to be able to do, the underlying values can become hidden behind factual criteria for working muscles, hearts and lungs etc. This contrast between divergent values in mental healthcare and shared values in physical medicine explains why there is an Anti-Psychiatry movement but not an Anti-Cardiology one.
Having now sketched some competing views of mental illness, and highlighted the potential connection between illness and values, we can now see what connections there are to the other questions raised at the start.

Applications to other questions?
First, is there a connection between mental illness and a justification for compulsory treatment? Fulford argues that his account sheds light on why psychotic illness justifies coercion. On his account, illness is an internally caused failure of ordinary doing. In the case of other illnesses, the failures concern difficulties in the execution of actions. But psychosis involves a loss of insight. It thus involves a defect in the reasons someone has for acting. And because actions are identified as the actions they are on the basis of why someone did them this leads to a constitutive failure to frame, rather than merely to carry out, an action. However, in general, peoples’ actions can excused when there is a breakdown in intention. If one does something which might normally deserve blame merely by accident, mistake or impaired consciousness, one can be excused because one is not responsible for the act. Illness can also act as an excuse.
All non-psychotic illnesses… involve… instrumental failures of ‘ordinary’ doing, difficulties in doing what one intends to do. And difficulties of this sort often mitigate and, if very severe, may even excuse. But in the case of psychotic illness, the failure of ‘ordinary’ doing … is a failure in the very specification of what is done. The psychotic, therefore… lacks intent… [H]e is thus in the same position as others who lack intent in that he is not responsible for what he does, and, hence, excused. [Fulford 1989: 242-3]
This idea that lack of intent excuses an action can be connected through two links to the problem of justifying compulsory treatment. First, psychotic illness, in which a subject lacks insight into his or her condition, undermines the subject’s capacity to form reasons and thus connects to defective intent. Secondly, a subject whose purported actions can be excused by defective intent, which may undermine their status as actions, is also by that fact the kind of subject whose autonomy can justifiably be overridden.
As Fulford spells out, there is of course a sense in which people with psychotic loss of insight clearly do form intentions, just as there is a sense in which they clearly do have reasons for their actions. The point is rather that, to the extent that their actions reflect psychotic loss of insight, their reasons are defective, in whatever (as yet to be determined) way delusional reasoning is defective. Defective reasons for action imply defective intentions, hence, excuse and hence also a rationale for compulsion by others.
This general approach promises to shed light on the key justification for compulsory treatment. There are, however, still some questions remaining. Do all cases that merit compulsory treatment involve defective intent? Why precisely does such a defect justify treatment? What exactly is the connection between the possibility of excusing purported actions because of some failure of intent and overriding the agent’s remaining autonomy? And what precisely comprises a relevant defect of intent? Is it right to say that there is a lack of intent, or a failure within the specification of intention, or an impaired intention or what? Nevertheless, it suggests that psychiatry carries with it quite specific medical ethical complexities which flow from the fact that it centres on disorders of human agency.
This line of reasoning suggests one factor in an answer to the next question raised at the start, too: should someone with a mental illness have less say over the nature of their recovery than someone with a physical illness? The extent to which mental illness can undermine a capacity to frame decisions has to be addressed in decisions about treatment and management. But there is another factor which pulls in the opposite direction. Just as both Fulford and to a lesser extent Wakefield argue the very idea of mental illness is value-laden, so it seems that recovery in mental healthcare is value-laden. This is because it is not merely a matter of getting batter, or returning to how one was before its onset, or returning to a statistically normal set of mental capacities. Rather it involves the section of a way of living which is right for the person concerned.
The Sainsbury Centre for Mental Health policy paper ‘Making recovery a reality’, begins by summarising some key points of emphasis which, it is suggested, characterise any broadly conceived recovery-based approach. These points include:
Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’…
Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability.
[Shepherd Boardman and Slade 2008: 0]
The Scottish Recovery Network summarises its views of recovery in similar terms:
Recovery is about living a satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms….
Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being.
[Scottish Recovery Network 2007: 3]
On this conception, recovery involves a value-rich personal choice. But given, as we have already described, there is a wide divergence of views about the values relevant to mental health and illness, especially to living a good life, this places much greater need for those with mental illnesses to be centrally involved in decisions about their care and there hopes for recovery.
The final question is harder. Can a classification or taxonomy of mental illness, such as the recently published DSM-5, aspire to be as objective as the Periodic Table in chemistry. Or is it more like the Top 40? According to Kendell and Boorse, mental illness (or more precisely disease in Boorse’s case) is a value-free, purely factual notion. But vas we have seen, their accounts face objections. According to Fulford and Wakefield, it is a value-laden notion. For Wakefield, this is a single value: harm. For Fulford, there may be a plethora of values. Indeed, the US psychiatrist John Sadler published a lengthy book on the wide variety of values and even kinds of values in DSM-IV [Sadler **]. If this is the case, what kind of classification or taxonomy can underpin mental healthcare?
First, any value-laden classification will be different from the value-free Periodic Table in chemistry. Even if the criteria for including symptoms or experiences into a particular category are factual and descriptive – like the criteria for a good apple – they will reflect original value judgements which cannot be measured by any instrument.
But second, the issue of the objectivity of a value-laden classification depends on the nature of the values involved. If they are mere expressions of subjective preference, like the Top 40, then they do not answer to anything objective and cannot aspire to being true. On the other hand, they might be thought to be expressions of something independent of any individual’s judgement as moral codes are often thought to be. If so, whilst distinct from the purely descriptive objectivity of the Periodic Table, classifications of mental illnesses would still have a more complex form of objectivity. This raises a key question: what is it to get such judgements right?

By its very nature, mental healthcare raises profound conceptual questions which call for philosophical rather than empirical research aimed at arriving at a clearer understanding of the underpinning ideas guiding healthcare. This chapter has illustrated this by addressing a fundamental question of what, if anything, mental illness is and briefly sketching some of the key ideas advanced over the last fifty years. One question these rival views differ on is whether mental illness, or disease, is a value-laden or value-free concept and, if the former, what kind of values.
Addressing that question, however, suggests connections to others, such as the justification of coercion, the nature of recovery and decisions made about it, and the objectivity of basic psychiatric taxonomy. A full and proper understanding of the nature of mental illness – the very idea of it – connects to other pressing areas. Philosophical understanding of mental healthcare is thus not merely an optional extra but a key guide to and resource for good practice.

Critical debate box: Grief, depression and the bereavement exclusion criterion
[To be added: Brief summary of the debate about the exclusion from DSM-5 of the bereavement exclusion criterion for depression.]

Austin, J.L. (1957) ‘A plea for excuses’ Proceedings of the Aristotelian Society 57: 1-30
Boorse, C. (1975) ‘On the distinction between disease and illness’ Philosophy and Public Affairs 5: 49-68
Boorse, C. (1998) ‘What a theory of mental health should be’ in Green, S.A. and Bloch, S. (eds) An Anthology of Psychiatric Ethics, Oxford: Oxford University Press: 108-115
Brown, W. and Kandirikirira, N. (2007) Recovering mental health in Scotland. Report on narrative investigation of mental health recovery. Glasgow: Scottish Recovery Network.
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Fulford, K.W.M. (1999a) ‘Analytic philosophy, brain science and the concept of disorder’ in Bloch, S. Chodoff, P. and Green, S.A. (eds) Psychiatric Ethics (third edition) Oxford: Oxford University Press: 161-192
Hare, R.M. (1952) The language of morals, Oxford: Oxford University Press
Kendell, R.E. (1975) ‘The concept of disease and its implications for psychiatry’ British Journal of Psychiatry 127: 305-315
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Szasz, T. (1972) The Myth of Mental Illness, London: Paladin
Wakefield, J.C. (1999) ‘Mental disorder as a black box essentialist concept’ Journal of Abnormal Psychology 108: 465-472