III
People who have histories of significant
personal loss but who never suffer from depression may be emotionally healthy,
or they may not. But they cannot, without further examination of the case, be
described as more healthy than those who do. Yet this is what modern psychiatry
has come dangerously close to doing. In an attempt to emulate the surface forms of scientific thought, psychiatric
evaluation of mental illness has tried to stop taking human reality into
account.
And here we come to the crucial point, the
point on which all modern debate about mental illness hinges, & which
constitutes the underlying source of all the self-deception that plagues this
debate.
We cannot make a judgement about what is or
is not healthy in the human mind without making an ethical judgement about how
human life ought to be lived. What
the medical perspective on mental illness conceals is that the question of what
is or is not mentally healthy is the same as the rather old-fashioned-sounding
question of what is or is not morally good, only approached from a secular
point of view. But because the decline of religious faith has made it
increasingly hard to reach agreement on the question of what is morally good,
we don’t feel comfortable asking it. So as a culture we have tried to persuade
ourselves it is really a medical question. The covert appeal of medicine in the
sphere of mental health is the hope of using science to reach consensus &
agreement on what are essentially ethical problems. The result of this
self-deception is what is misleadingly called the “therapy culture” where
illness is used as a pretext for failing to exercise personal responsibility.
The syndrome is misnamed however because it is not the psychotherapy profession
but the medical profession that has been responsible for encouraging the view
that moral problems can be solved in medical ways.
That being said, however, the fact is that
with the decline of religion & the advent of a secular culture the nature
of moral & ethical problems has
changed. It is no longer legitimate to talk of unconditional moral rules as it
was in a time of general religious faith. That era is gone. We do now have to
look at ethical issues in the context of emotional health. But two things need
to be born in mind here. First, when we speak of illness here we are speaking
of something fundamentally different from physical illness & it cannot be
cured in the same way that physical illness is cured. Second, a recognition of
the ethical or moral dimension of emotional illness does not mean we expect to
derive a code of answers as to how men should live but rather that we recognize
that man, as a matter of fact, does not know how to live. It is quite true that
moral problems have become problems of health, but this is not health in the
sense that one is taught to use that term in medical school. And it is equally
true that problems of mental illness have become problems of morality, but this
is not morality as it was ever taught by the priests. Because, in a secular
world, questions of morality & questions of health can no longer be kept
separate but have fused with each other, each has fundamentally altered the way
we understand the other.
Every civilization has developed codes &
rules of morality of one kind or another because, as Nietzsche remarks, man is
the sick animal. In other words, man does not know what kind of
life is optimal for his nature so he is always trying to patch up his ignorance
with the scraps of moral teaching. This is an unstable & dangerous
condition for any animal to be in. And this is the source of our turmoil. What we see in human
history is the perennial re-awakening of ethical debate about how man should live, alternating with the perennial
attempt to shut such debate down. We are always on
the way to finding out yet again just how divorced we are from ourselves, or on the way yet
again to trying to forget it.
Man is in an impossible position because not
only does he not know how to live, he also cannot bear the anxiety of knowing
that he does not know how to live. So he tries all the time not to know it. The
history of ethics & morality is thus the history of an animal essentially
frightened of itself, trying bravely to confront itself, but always
compromising this attempt with hypocrisy. And it is into this quagmire of
half-truths & self-delusions that one perforce ventures as soon as one
makes any serious attempt to address the problem of mental health &
illness.
For instance, the diagnostic categories in
the Diagnostic & Statistical Manual of
the American Psychiatric Association constitute a catalogue not of types of
physical malfunction but rather of ethical judgements about what are healthy & what are
unhealthy patterns of human life. It is just that here, instead of being made
by one individual, they are made by a committee that has sifted a large number
of individual judgements. As such, there is absolutely nothing wrong with this.
It helps to clarify diagnostic categories, it gives coherence to debate, &
it gives us a picture of consensus thinking on these matters among
professionals at the present time. A problem arises only if we are encouraged
to think of these categories as having been
derived in some way other than as a consequence of ethical judgements about
what a healthy life should be. In fifty years from now some of these diagnostic
categories will still be useful. But quite a few will merely be quaint
reminders of what some people thought life was about fifty years ago.
Anyone who is engaged in helping someone in
mental distress faces the responsibility of having to make an evaluation of
just how far that person deviates from some ideal of health. If a patient is
behaving in a wildly destructive manner, or is clearly prey to delusions, or is
completely unable to cope with everyday things, such an evaluation is easy. But
most people who come seeking help with their unhappiness are not behaving this
way. Most are suffering a vague but persistent sense of unease, or anxiety, or
hopelessness. More often than not they cannot express clearly what it is they
feel wrong. This is when judging the degree of illness the patient is suffering
becomes hard, & the likelihood of achieving consensus starts to diminish.
And this is where the clinician must be able to exercise personal judgement.
This is challenging & potentially
stressful because to make such judgements consciously & rationally the
therapist must have a good awareness of his own
values. He must be able to view them critically. And he must be comfortable
with the fact that that they are not absolute or God-given but are particular
to him & are the outcome of his own history & his own evaluation of
things. They can never be entirely appropriate for others. At this point the therapist,
if he is any good, is on his own. Under this pressure, the temptation for the
therapist to seek an escape in a consensus view of the matter may be strong.
But for him to do so is to abnegate responsibility, because no such consensus
exists. He is now dealing with the human soul in its living solitude.
To ask the question, what is the best way
for this patient to live? (not all
patients, but this patient), is necessarily to become aware that our own
values are specific to us. But each of us is limited in our ability to look at
our own values dispassionately. In some measure, all of us are fearful that if
we give up the assumption that our perspective on things is somehow the right
one, right not just for us but in some ultimate way for everyone else too, our sense of isolation
will become intolerable & our sense of self will start to unravel. We can
accept that some of our views on things may be personal to us & have no
authority other than our own private judgement. But it is an exceptionally
strong individual indeed who is happy with the idea that all of his views are
without any sanction other than his own judgement.
This anxiety about emotional isolation is
the professional neurosis of psychotherapists & is at the root of the
insecurity & mutual irritation that is such a prominent characteristic of
them. Unconsciously those of us in the profession seek support for our own
judgements among other therapists. But then, when inevitably we don’t find
this, or find it in less than complete degree, we try to hide from our sense of
shame over our dependence in an attitude of paranoia towards our colleagues.
Professional associations of psychotherapists are notoriously unstable &
prone to faction, for just this reason. And they always will be.
And this same anxiety over emotional
isolation is why psychiatrists as a
profession, & many psychologists & psychotherapists also, cling
with such irritable tenacity to the supposed authority of “science”. The
perennial appeal of “science” in the field of mental health –whatever “science”
is conceived to be – derives from the hope that it will give us an objective
basis for evaluating mental health that is
independent of our own judgements.
It is one of the characteristic dogmas of
modernity that science gives us access to a world that is purified of human prejudice & value. Nothing could be further from
the truth. Science is as free of human prejudice as the claw of a cat is of cat
prejudice. Our devotion to science reveals only how many of our most powerful
prejudices it confirms. And it is precisely because it confirms so many of our
prejudices that we need to pretend to ourselves it is free of them. Our own
interests will not allow us look at how riddled with our own interests it
actually is.
In psychiatry we have bamboozled ourselves
into believing that science holds out an escape from having to make the kind of
value judgements that arise everywhere in treating mental illness, & thus
offers an escape from the stress of having to achieve a sufficient degree of
critical self-mastery to be able to make such judgements in something
resembling a balanced & rational manner.
For it may be true that a man can have a
chaotic emotional life & be prey to a whole menagerie of personal neuroses
& complexes & still be a first-rate physicist, or chemist, or surgeon.
But without a significant degree of self-knowledge & a mastery of the self
a man certainly cannot be a scientist or therapist of the soul. This kind
of science makes
demands on the character of the investigator that science elsewhere does not
make. And this is why the sciences of elsewhere are repeatedly called upon in
mental illness. They look like a respectable escape route from the central frightening
challenge that understanding mental illness poses: know who you are & how
you differ from other people.
For instance, if we could convincingly show
that depression, or even a particular kind of depression, were caused by a
malfunctioning of particular neuronal circuits in the brain then we could
without hesitation classify it as an illness. The need to make an ethical
appraisal would be overcome because we could point to a simple distinction
between a circuit that functions normally & one that functions abnormally.
It would cease to be a mental illness in the same way, for instance, that
Down’s Syndrome & dementia have ceased to be mental illnesses. Like them,
it would be a physiological illness with certain associated mental impairments.
We would be released from the difficult task of making an ethical assessment as
to whether a particular case of depression was an essentially healthy response
to difficult circumstances or a difficult history, or on the contrary whether
it should be more usefully classified as an illness, as a pathological
inability to deal with a reality that a healthy person should be able to cope
with.
And this, essentially, is the most important
driver behind the search for physical causes of mental suffering. It is a wish
to escape from the fundamental ethical ambiguity of mental illness. It is the
wish for a certainty that would take out of our hands the responsibility for
making difficult, uncertain decisions. It is a regressive wish & in the
very difficult field of emotional pain it has unfailing appeal.
Science is genuine science so long as we
handle it as our intellectual servant & take responsibility for how we
apply it. Once we start to fetishize it & treat it as our emotional master,
as some kind of intellectual equivalent of the categorical imperative, it
becomes merely a neurotic symptom of denied anxiety. And in large measure
psychiatry, & those regions of psychotherapy that crave scientific
respectability, have done just this.
Psychiatry has lost the habit of thinking
ethically, contextually & historically. But when we stop thinking in this
way we lose sight of the mind. To keep the mind in focus we must ask, what is
the cause of emotional distress in the past of this patient? How is the distress symptomatic of this patient’s attempts to create a
better future out of the past? To what extent is the patient failing, & to
what extent succeeding, in developing a future that will be creative &
fruitful for him? Until we place the
patient’s distress in the context of his past
& his future we are wandering
without a compass, however scientific we may flatter ourselves our procedures
are.
But I wish not to be misunderstood here. The
correct application of physical science is a vital part of our war against
destructive formations in the human mind. The mistake psychiatry has made is
not in trying to get a better grasp of the functioning of the brain &
nervous system. We need to know much more about these things than we do at
present, & we will. Anti-depressant & anti-psychotic medication are
saving lives & releasing people from intolerable suffering every day. This
is not the problem.
The mistake psychiatry has made has been in
endorsing the view that it is okay to give up the treatment of patients first
& foremost as unique life histories:
that is, as people who have had to make unique choices, who have faced, &
who still face, unique dilemmas, & who have to try to create unique
futures; & for whom there will be uniquely
healthy solutions, with no parallels in the life of any other human being.
By excluding this essentially ethical perspective on mental illness psychiatry
has misled public perception of what it is & it has distorted public policy
on how it is best treated. In its wider responsibility to the public debate on
mental health psychiatry has lost its nerve.
Every aspect of physical health can be
expressed in terms of a healthy norm. Each part of the health of the structure
& functioning of any human body can be described in terms of its degree of
deviation from an ideal numerical ratio. Mental health in contrast is nothing
like this. We suffer mental distress because for each of us there is a unique
state of flourishing, fruitfulness & creativity, & because to achieve
this state we have to overcome our fears of not being quite like anyone else.
You can be a paragon of physical health & still be a worthless individual.
This is not possible in mental health. Without at least a modicum of honesty
& courage in confronting oneself mental health cannot be said to exist.
Mental health is ethical health.
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