Thomas Szasz and The Myth of Mental Illness fifty years after publication

Brendan Kelly’s portmanteau paper ‘The Myth of Mental Illness fifty years after publication: What does it mean today?’ has been accepted for publication by the Irish Journal of Psychological Medicine. The contributors are Pat Bracken, Harry Cavendish, Niall Crumlish, Seamus MacSuibhne and Tim Thornton and Thomas Szasz has supplied responses to our comments.

Szasz doesn’t seem as happy with my 800 words as I thought he might have been. His comments on me run as follows (you’ll have to wait for the paper to see what else he says).

Some of Professor Thornton’s views appear to be in agreement with mine, and some seem not to be. After summarizing my reasons for rejecting the concept of mental illness, he writes: “The argument here starts from the assumption [sic] that mental illness and physical illness involve deviation from different norms.” My argument did not start from an “assumption.” Instead, it started from the observation that we use the terms “bodily illness” and “mental illness” differently: for example, psychiatrists regularly deprive patients of liberty, while other physicians do not do so. Problematically, much of Professor Thornton’s writing is abstract and abstruse, such as the following:

[E]ven if mental illness is defined by, or identified via, psycho-social norms, this need not imply that it is identical to or constituted by such deviation. 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. (Firing the gun may be picked out as the cause of the death of the president; but it is not identical to the death: it slightly predates it.) If so, Szasz’ argument fails. To establish his conclusion he would need to establish the truth of a kind of mental illness behaviourism which goes beyond merely and plausibly highlighting the role of societal norms in picking out illness.

Mental illnesses are not “picked out.” They are constructed and deconstructed, exemplified by the history of homosexuality qua mental disorder. Professor Thornton states that I need “to establish the truth of a kind of mental illness behaviourism.” I do not know how to do such a thing and do not understand what would be the practical consequences, if any, of my accomplishing this feat. Would the courts, the legislators, and the medical-psychiatric system then abolish psychiatric controls and excuses?

“Take the case,” Professor Thornton writes, “of those people who claim that the inner voices that they hear are indicative not of a pathology but of their membership of a different community. Their experiences are a deviation from a societal norm but does the deviation also amount to a pathology?” The answer depends on our/the definition of “pathology.”

Clearly, the demarcation-separation of psychotherapy from somatic medicine (or the rejection of such a demarcation-separation) is of paramount economic, ideological-professional, and political concern to numerous parties. In this connection, let us contrast Karl Jaspers’s and Paul McHugh’s – both famous psychiatrists – reactions to this challenge. Jaspers – today better known as a philosopher – observed: “All therapy, psychotherapy and attitudes to patients depend upon the State, religion, social conditions, the dominant cultural tendencies of the age and finally, but never solely, on accepted scientific views.” Paul McHugh – long-time chairman of the psychiatry department at the Johns Hopkins University Medical School – writes:

As we psychiatrists start to teach our discipline to beginners, we confront a qualm among some students that psychiatrists may not be “real” doctors. “What else,” we respond somewhat defensively, “might we be?” “Well,” comes the answer, “medicine is an applied natural science directed toward sick people. Psychiatric patients seem not sick but troubled, and psychiatric effort more guidance than curing. Perhaps the natural associates of psychiatrists are not physicians and surgeons but counsellors, ministers, social workers, and even, heaven forbid, lawyers.” We flinch at this view and sometimes turn cranky.

phenomenology or Phenomenology of illness?

Distracted at home by other books that had to be read for work, I took Havi Carel’s slim book called simply Illness on my short walking trip last week (Carel, H. (2008) Illness, Stocksfield: Acumen). I first met Havi at one of Rachel Cooper’s one day workshops on philosophy of psychiatry at Lancaster. It must have been in 2007. We had an argument (a friendly argument, that is) walking back from lunch about the prospects of biological functions to naturalise illness. The third thing I noticed about her, however, was that she had an oxygen cylinder in a backpack.

Reading her book, however, I realise that this cannot have been as long after she’d found out that she had a life-threatening illness as I seem to have assumed. The book is a meditative reflection almost forced from her by a serious medical diagnosis (of the disease LAM) received under less than ideal conditions (though there could be no ideal conditions compatible with the diagnosis itself) on 10 April 2006. Its aim is a kind of phenomenology of illness. But what is particularly compelling about it is that, with one exception, the chapters are driven more by a description of the lived experience of illness (‘phenomenology’, perhaps) than by an explicitly philosophical agenda (‘Phenomenology’).

The one exception is a (necessary, albeit) chapter on fearing death which takes Epicurus and Heidegger and unpacks their ideas. The agenda in that chapter is thus set by those past philosophers and it’s perhaps significant that their arguments seem less compelling, less true, than everything else in the book. I’ve never understood why our understanding of being rather than non-being requires that we actually inevitably die. Why isn’t the fact that we were once not alive or even the mere possibility that we might not have lived enough? A decent argument (from Heidegger rather than Carel in the first instance) would help.

In all the other chapters, philosophical ideas are organically woven into a narrative which is driven by a first personal account. This first person approach is obviously the best way to give the book its substance and force but it came as a bit of a shock to me. I had expected a drier and a more explicitly scholarly book. But that would have been much less good. Instead the analysis – and this is the challenge for philosophy – has to cope with the enormity of the experience whose description (especially the two Horrible Men) rings completely true. Havi outlines a possible philosophically-informed response based on the chapter mentioned above. (That is why it is necessary for the overall argument.)

In the end, I’m not sure that philosophy (perhaps ‘Philosophy’ would be better) is up to the job. Just as the sceptical challenge seems more potent than any philosophical answer to it (cf McGinn on trust of philosophical problems over solutions), so the existential predicament Havi describes seems more potent than any philosophical response to it. Whilst she has cruelly had the nature of that predicament forced more urgently on her than it is on most people, it’s the predicament we all face. So this is a bit of a problem.

Walking and knowing what it's like

Lois and I booked some holiday and, this week, walked the Cumbria Way: a five day route along the North South axis of the Lake District. We had enjoyed three dry and sunny weeks in late April, when we formed the plan, but this week was very wet indeed. (What should one do when faced with a stream too wide and deep to get easily across? We waded in our boots sacrificing dry feet to up the chances of making it across without falling over.)

As the weather deteriorated, I began to wonder about the pleasure of walking in such conditions. In good weather, there is a variety of sensory-based and purely aesthetic pleasures (the sun on one’s skin, the views, characteristically walking-based conversations with companions etc). But these do not survive solitary tramping hunkered down in a cagoule in the rain. What does survive, I think, (but merely as a pleasure like any other, to be weighed against discomfort) is cognitive. It is the pleasure of knowing how parts of the walk connect together. So, for example, Borrowdale connects via Langstrathdale to Langdale. But I now know what that connection looks like, how accessible it is relative to a normal day’s walk, how much it matters to be carrying a pack over it and there’s pleasure to be had in such knowledge.

The worry, though, about that line of thought is that it might slide into a too personal form of knowledge: that the experience one has in doing the walk does more than is safely domesticated through demonstrative thought and other innocent notions. One would not want that to seem to support merely private knowing.

Module validation as philosophy?

Yesterday my colleague Gloria Ayob gave an excellent paper on the role of location in the sense of demonstrative thought. It had all the virtues of good philosophy: a clear and powerful argument with a nice final therapeutic flourish. It helped lift the low mood I’d had since earlier in the day.

These days university courses (or ‘modules’) are carefully vetted at the planning stage. The days of scribbling down a course outline on the back of an envelope are long gone. And thus, for example, the following could no longer happen. As a masters student I attended a course on the philosophy of the Einsteinian universe by Jeremy Butterfield (pictured). On the first week, and although it wasn’t on the reading list, he suggested that it would help if we began, by way of a contrast, with some thoughts about the Newtonian universe. We didn’t finish that in week one so carried that business onto week two but again time ran out. As is perhaps now obvious: we never reached Einstein but the impromptu course was excellent.

That was, no doubt, an exception. (Not every lecturer is a Jeremy Butterfield.) The process of validation helps make sure that the aims and planned outcomes of a whole course or programme do indeed supervene on those of individual modules etc. Such formal constraints are easy to violate in the rush of thinking through a teaching programme.

Because of problems with the timetable I needed an urgent validation for a philosophy based research methods module and I am very grateful to colleagues from both the administrative side and from other subject areas who were willing, inconveniently for themselves, to do this. But part way through, questions that had been to do with making sure that the stated aims and outcomes for the module matched that of the programme as a whole modulated instead into a question of how research in philosophy was possible. A bit surprised I asked: do you really want me to justify the application of ‘research’ to philosophy in general, to explain how it’s possible? ‘Yes, if you can do it briefly.’

Having already pressed the idea that philosophical research was a matter of framing good arguments I had then to explain why the question was tricky in a familiar way. Either the conclusions of arguments are contained in the premises in which case the arguments seem redundant or they are not in which case the arguments are invalid. But whilst this would have been an enjoyable discussion over a pint, in the contrasting situation where the implicit threat was that a course might not be validated, it seemed rather a depressing turn of events. (At the initial validation of my masters I was also challenged on just this point: philosophy, surely, cannot claim to do research!) I’m sure that if a philosopher challenged a chemistry research module by saying: ‘Chemistry purports to research the hidden micro-structures of substances but since these are under-determined by all humanly available evidence how is chemistry so much as possible?’ then that would be ruled out of court. But it is OK to ask philosophy this.

The irony of course is that philosophy is quintessentially the subject for whom its status as a subject is an issue (philosophy as Dasein). The problem it seems to me is a dilemma. On the one hand, one wants to characterise the outputs of philosophy as world involving. On the other, one wants to characterise its methods as within our conceptual sovereignty (to misuse Quine) without the need for favours from the world. But the latter don’t seem to be able to reach as far as the former. If guided by the latter, one has to rethink the outputs not as world involving but merely as limits on how we represent or think of the world (this is Stroud’s response to claims about transcendental philosophy made by Strawson).

That in effect, ironically enough, is how the module validation itself process works. There was no suggestion yesterday that any of the conditions to be applied in advance of agreeing my course would affect how it was to be taught (that’s the analogue of world-involving). All that I needed to change was how I represented how it is taught. The process of validation is a (strained, albeit) metaphor for the problems of philosophical research.