Are mental disorders physical or ethical?

One of the things that has happened in our culture over the last 300 years is the shift from theology to morality to psychiatry. Conditions that were once deemed vices are now considered diseases. Gluttony has become obesity. Despair has become depression. Lust has become sex addiction.

A few ornery voices on the right, like Theodore Dalrymple, Peter Hitchens and Frank Furedi (he’s on the right, isn’t he?), complain about the rise of the discourse of disease and therapy, and the gradual disappearance of the idea of moral responsibility. Recently, Dalrymple and Hitchens fulminated against Russell Brand’s contention that drug addiction is a disease, insisting instead that it’s a vice, and a crime.

Most of us probably sympathised more with Brand, just as most of us probably agreed with that cartoon doing the rounds a few weeks ago, ‘what if physical illnesses were treated like mental illnesses’. Labeling things like depression or alcoholism ‘vices’ seems medievaly cruel and heartless. Many people are now genuinely offended by the idea of the individual as an autonomous free agent, which they see as an invention of neo-liberalism.

This fundamental cultural shift comes from the rise of materialism since the Scientific Revolution, and the growing popularity of the idea that, as Julian Offray de La Mettrie put it, man is a machine. If the machine starts doing strange things like gorging on chocolate or killing people, that is a mechanical malfunction rather than a moral choice, and should be treated accordingly, with drugs or behavioural modification.

So which view is right? Are mental disorders physical, or ethical?

I think that, paradoxically, both views are right. Humans are machines, determined by our genes, our neural chemistry and our environment. But we also have the capacity to make moral choices, and should be held accountable for our moral mistakes. Ignore either side of this polarity, and you fall into error – either the error of thinking man is entirely a machine without any free will, or thinking man is a completely free agent without any limits on his rationality and choice.

The paradox of humanity is that we are both caused physical objects, and also moral subjects with a limited capacity for transcendence. That small capacity for transcendence means that, unlike every other animal, we can re-programme ourselves. Our personalities are not set in stone. We can use our rational consciousness to choose a direction in life. And that rational consciousness means we can also be held accountable for our actions, rather than treated like helpless children or dogs.

With regard to mental disorders, this means they are best understood as both causally determined, but also involving ethical errors about the best way to flourish. The gambler, the drug addict, the food-gorger, the social phobic, even the depressive, are not simply the victims of physical malfunctions. They are the makers of ethical errors. They may have inherited these ethical errors from their parents, their genes or their culture, but they have the sovereign human capacity to change these errors.

The Greek philosophers understood that bio-psychology and ethics are not two separate departments. They understood that mental disorders like anxiety are both diseases and vices or moral errors. They are diseases of our reason, diseases of our moral capacity to choose a wise course in life. And the cure for this disease is philosophy,  by which they meant psychology + ethics + economics + politics + theology.

Today, at the apex of the materialist worldview, we are beginning to return to the ancients’ wisdom that humans do have self-control and the capacity for moral reasoning, and that these things are important for helping us escape problems like obesity or addiction.

The most scientifically credible treatments for depression, anxiety and many other mental disorders is Cognitive Behavioural Therapy (CBT), which was inspired by Greek philosophy, and 12 Step programmes like Alcoholics Anonymous, which grew out of Protestant Christianity. Neither CBT nor AA use the old language of sin or vice or moral blame, but they both insist our ability to recover from mental disorders depends on our reasoning and moral choice (as well as help from a Higher Power, in the case of AA).

Neither CBT or AA are glibly optimistic about our ability to change ourselves. Both recognise the terrifying power of mental disorders  to wrap themselves around us like a parasite, to lie to us and utterly transform our personality. They also recognise that, in some cases like dementia or schizophrenia, our biology may destroy our capacity to reason. But they also recognise our stubborn human capacity for transcendence and re-birth.

Our capacity for transcendence is just a capacity, and Aristotle insisted it can be ruined by our environment, by a particularly poor or abusive childhood for example (although the Stoics would have argued that even abused slaves like Epictetus can show extraordinary moral courage). And our moral capacity is also bounded by the power of habits. Decisions harden into habits, habits harden into personality traits, personality traits harden into biographies. Character, as Heraclitus put it, is destiny.

I know from personal experience how poor life-decisions gather momentum until they become overpowering and chronic mental disorders. When I was a teenager, I did lots of drugs, and ended up traumatizing myself. Poor life-choice. The trauma hit me at university, and led to me becoming increasingly socially phobic. Bit by bit, what started as a free choice not to go to a party hardened into an involuntary compulsion – I would be terrified at the thought of going to a party.

At that time, I was addicted to the I-Ching, the ancient Taoist book of divination. I constantly asked it questions to try and work out what was happening to me. I often got hexagram number 29 – K’An, The Abysmal – as a reply. The second line of it tells us:

Repetition of the Abysmal.
In the abyss one falls into a pit.
Misfortune.

Which the commentary explains as:

By growing used to what is dangerous, a man can easily allow it to become part of him. He is familiar with it and grows used to evil. With this he has lost the right way, and misfortune is the natural result.

Things get away from us. The state of vice or sin can be compared to the episode of The Simpsons, when Homer is standing on a skateboard at the top of a hill, overlooking a canyon. All it takes is a small push at the beginning – one bad life-choice or unlucky life-event – and things quickly gather momentum, until you are hurtling towards the abyss and it’s very difficult to get off the skateboard.

We always have the choice to get off the skateboard, but it gets harder and harder, partly because it takes humility to admit we are heading in the wrong direction and we need help to change. Our egos love to delude ourselves that everything is alright, like the optimist who jumps off a building and says, as he passes each floor, ‘so far so good’.

The unfortunate consequence of our nature as moral subjects is that people have to choose to get off the skateboard. Loved ones can’t make them do it. As the joke puts it, ‘how many psychotherapists does it take to change a light-bulb? One, but the light-bulb must want to change.’

Often, when I do philosophy talks, I meet mothers whose teenage or young adult children are deeply depressed, but who won’t do anything to get better. They are heading for the abyss. The poor mothers often wear brave smiles, but you can see how destroyed they are inside. And they don’t know what they should do, they say that their boy (it’s usually a boy) just won’t try anything to get better and gets furious with them if they try to make them.

It makes me think that fundamental to recovery from mental illness is some survival mechanism kicking in. People need a moment of epiphany, when they wake up from the automatic cycle of self-destruction, and think ‘my God, I’m killing myself’. They need to stop blaming their mother or father or genes or God for their shitty life, and think, ‘I’ve got to do something’. And when that self-preservation kicks in and they take responsibility for their beliefs and habits, they might have a chance of getting better. But they need that moment of insight and that sudden urge to survive.

Drugs may well be a part of that recovery. But a lot of the therapeutic power of pharmaceuticals may well be placebo (just as an addict praying to a Higher Power may be placebo). What is really helping us recover is the realisation ‘shit, here comes the abyss, it’s time to change direction’. It may not be your fault you’re heading for the abyss, it might have been your shitty childhood that gave you the first push down the hill, but ultimately it’s your choice whether to get off the skateboard or not.

Russell Brand realizes, I think, this paradox. He says addiction is a disease, but a spiritual disease. We make bad life-choices or suffer traumatic life-events, and then things get their own momentum. The treatment for such diseases involves lots of love, sympathy, and perhaps pharmacology. But Peter Hitchens is right too – it also involves individuals making better and wiser moral choices.

Comments:

  • Mark Vernon says:

    Great to have your first blog post of the new year. Thank you!

    I wonder what difference the well-evidenced insights of developmental psychology suggest too – in particular, the idea that we probably all have elements of our psyche, and so of our moral capabilities, that are stuck at certain stages and need working on to tackle fears, anxiety etc and the moral difficulties related to them. That probably requires help from another, as a key insight in developmental psychology is that we learn by internalising good psychological ‘skills’ – the ability to digest difficult emotions etc – from another, in early years usually a parent.

    Also – and you’ve heard this from me before, so forgive me – I think there are more evidence-based options than CBT. The American Psychological Association’s 2012 resolution on psychotherapy was particularly important to me – online here: http://www.apa.org/about/policy/resolution-psychotherapy.aspx – with the crucial clause here, to clutter up your blog:

    ‘Be It Resolved that, as a healing practice and professional service, psychotherapy is effective and highly cost-effective. In controlled trials and in clinical practice, psychotherapy results in benefits that markedly exceed those experienced by individuals who need mental health services but do not receive psychotherapy. Consequently, psychotherapy should be included in the health care system as an established evidence-based practice.’

  • Rowina says:

    Hey Jules, I too saw that cartoon floating about on facebook and thought “why is depression now considered a disease that can be compared to having a knife dug in your side?”. Was very enlightening and helpful to read the history of this type of thinking. Great post Jules! Rowina

  • Jules says:

    Thanks Rowina!
    Jx

  • Stephen says:

    I think the problem lies in our paradoxically scientific dogmas of specialisation. Generalisation is viewed as the poor cousin of specialisation. This leads to blinkered detached research that often misses the links and big picture worldviews that we need to get a balanced perspective on social phenomena.
    Thus researchers stuck in their own faculty bubb!e will compartmentalise the issue in their own conceptual language.
    Instead of phenomena being as a result of a complex web of social interaction, they are pigeonholed into problems due to an ‘x’ factor ie cholesterol, red wine, dark chocolate etc
    The news is full of such stupidity. Fad diets are a manifestation of a specialisation fetish.
    And returning to the topic, blaming one particular element is dangerous and silly.

  • Gerard Mikols says:

    My comments are more general to Jules effort to bring philosophy back to every day decision making and remind us like Hadot that the spiritual exercises of the Greeks were not necessarily religious. I believe it is a very positive sign. I have long worried that science has knocked philosophy into the minutiae for quite some time and religion and the “woo woo” have filled the gap. My true hope is that more and more people think for themselves while being rigorous and data driven in their conclusions and take feedback from those who disagree with them and become most uncomfortable when they are too confident in what they know. One of the valuable warnings of Socrates. I know I am dumb, but unfortunately everyone else is even dumber:-) or too many are very dumb too often. Thanks Jules for doing what you are doing and glad to learn about the Socrates Cafes.

  • Stephen says:

    Slightly off topic, but again relevant in a more general sense. I struggled to empathise with what Jules had described as a spiritual moment when he was hurt skiing: I think Jules described it as a feeling of complete love and sense of something unbreakable.

    Anyway, from reading Jules’interview with Guite, this led me onto the Inklings and onto Lewis and Tolkien and myth then onto Joseph Campbell. I have just finished reading ‘The Power of Myth’ and I came across this part about becoming ‘illuminated’ and how it happens. I linked Jules’ skiing accident with the car crash…

    from The Power of Myth
    conversations with Joseph Campbell and Bill Moyers

    MOYERS: Is art the only way one can achieve this illumination?

    CAMPBELL: Art and religion are the two recommended ways. I don’t think you get it through sheer academic philosophy, which gets all tangled up in concepts. But just living with ones heart open to others in compassion is a way wide open to all.

    MOYERS: So the experience of illumination is available to anyone, not just saints or artists. But if it is potentially in every one of us, deep in that unlocked memory box, how do you unlock it?

    CAMPBELL: You unlock it by getting somebody to help you unlock it. Do you have a dear friend or good teacher? It may come from an actual human being, or from an experience like an automobile accident, or from an illuminating book. In my own life, mostly it comes from books, though I have had a long series of magnificent teachers.

    MOYERS: When I read your work, I think, Moyers, what mythology has done for you is to place you on a branch of a very ancient tree. You’re part of a society of the living and dead that came long before you were here and will be here long after you are gone. It nourished you and protected you, and you have to nourish it and protect it in return.

    CAMPBELL: Well, its been a wonderful support for life, I can tell you. It’s been tremendous what this kind of resource pouring into my life has done.

    … and so I think I get it now, in some respects. A great book by the way and well worth a read.

  • Gerard Mikols says:

    It is interesting when people take complex and personal feelings that might even have a conceptual component and assign words like awe and illumination. This can be quite misleading.

    We know drugs can induce all kinds of feelings and it would be easy to assign words like awe and illumination to these feelings. I have had many feelings and even mental events that I could call awe inspiring or illumination, but don’t see why this at all connects to religion, god or the spiritual.

    The most compelling notion of the word spiritual for me is efforts to get better and to better understand using our ability to reason especially using concepts and learn and in the process make things better for ourselves and others in the way that the others independently conclude you are making things better for them.

    It is the lack of manipulation and dishonesty and the willingness to see the painfully honest. I think for the most part humans know when they are lying and manipulating for their own personal gain versus when they are genuinely trying to be honest and accurate and trying to make things better for more then themselves and their family and friends.

    • Stephen says:

      When you say that drugs induce similar feelings such as awe and illumination but that we don’t assign those descriptors, then perhaps that’s because we know those mental states have been artificially generated.

      I am far from being competent to argue in this field but what I do know is that because a human being can achieve a sense of awe/spirituality/illumination etc through a life experience, and that perhaps an indistinguishable feeling can be induced by drugs, this does not mean that they are the same things. It does not mean that the former is connected to the latter in any other way others than what it feels like. And as we know an identical feeling can be aroused by independent sources. For example, a feeling of sleepiness can be as a result of fatigue or it can be as a result of a blow to the head, or a dose of morphine or just that time of day on your biological clock – Nana nap time.
      So I have a problem when I feel that someone thinks they have all the answers and challenges others on points of conceptualization when indeed the area is vast and complex.

  • Gerard Mikols says:

    I am reading Philosophy for Life and Other Dangerous Situations and was interested to learn that Hadot is a mystic. Interesting. I also see that Jules finds the third explanation for consciousness in his book put forth by Dawkins and Gould improbable. Our only evidence for intelligent life are humans and maybe other mammals. As far as we know before humans, there is no evidence of intelligent life. The assumption that God is merely random with stability merely created by the external circumstances as more supportable by the evidence than God is an intelligent force. Laws arising out of randomness seems more probable than the notion of an intelligent god. An intelligent god seems more like humans imposing themselves on the universe. Seems like a random consciousness in humans that has no real benefit is more probable than an intelligent god.

  • Gerard Mikols says:

    Hmmm. Why are drugs any more artificial than religion? I certainly have many more questions than answers. Maybe drugs users are more genuine than religious folks. Anyone who asserts anything can be called arrogant. Maybe we should stop asserting.

  • Stephen says:

    I don’t recall mentioning that drugs were more artificial than religion. I believe I mentioned that something that might be described as ‘illuminating’ might be induced artificially by drugs as opposed to the experience of Jules’ during his skiing episode. I further posited that a certain perceived state might be arrived at as a result of independent causality. Thank you.

  • Gerard Mikols says:

    Sorry for the misunderstanding Stephen. Thanks for the clarification.

  • Amy says:

    I find it interesting that there is a move towards a purely materialistic definition of human behaviour that seems to deny the possibility that we can change, and the incongrous discovery that our brains are in fact plastic. Perhaps culturally we have started to see anything that is hard (and what’s harder than changing automatic and often addictive behaviour) or that doesn’t come naturally to us as impossible because it’s easier to believe we are 100% driven by our genes and therefore have no responsibility for how our lives turn out.

    This article (http://www.theguardian.com/lifeandstyle/2013/dec/14/change-your-life-blame-lazy) from This Column will Save your Life in the Guardian, and in particular the comments, seem testament to the idea that people believe that self discipline is easy for those who have it and those of us who don’t, well, there’s no point trying, cause it’s really hard and uncomfortable. How they can possibly explain the success of Alcoholics Anonymous or CBT, I don’t know.
    This is why I believe history (an cultural history) is so important, so that people can see that what we take as fact (in this case being unable to escape your genes, as well as neuroscience) is often at least partly a reflection of the culture we are living in.

  • Amy says:

    Sorry, forgot to say, excellent article to start the new year!

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