My last essay attracted more attention than any of my others. A number of fellow bloggers posted links to it, and a couple of mental health activist sites picked it up. This was very gratifying, but in reading the comments here and elsewhere, I see that more must be said about “mental illness” as a dead concept. In particular, I should propose alternative ways of viewing conduct problems.
As The Death of Mental Illness made clear, I’m well aware that speech and behavior can sometimes appear so out of control as to demand assistance. Some commentators have opined that whether we call these tendencies “illnesses” or not is merely a question of semantics. No doubt there is some truth to that, but because of stigma and damaging effects on self-image, the words we choose have important implications for human life.
In summary, here are my reasons for doubting the disease paradigm: 1) It is difficult to draw a line between “mental illness” and normal variance. 2) Which disruptive behaviors get labelled as “mental illness” reflects cultural bias and not medical science. 3) The medicalized diagnostic system is supposed to guide the prescribing of pharmaceuticals, but psychiatric drugs are neither specific to particular diagnoses nor very effective. 4) Although brain alterations occur with longstanding behavioral disorders, there is no evidence of causative organic pathology to explain any “mental illness.” (This last point was not included in the essay, but was outlined in my response to one of the comments.)
It’s easier to tear down an edifice than build a new one. We obviously need some picture of behavioral derangement, but if “illness” is an inappropriate paradigm, what do we replace it with? I already mentioned the view of traditional societies: disordered conduct results from spiritual maladies. But this vague and often mythic framework will not satisfy moderns who demand scientific explanations. I can think of at least two possibilities that are consistent with contemporary science. The first lies entirely within materialist philosophy, and the second requires one to embrace the findings of modern consciousness research, and so strays beyond strict reductionist dogma. I’m going to address the less controversial viewpoint today, and will defer the more edgy one until another time.
In a recent essay I argued against the modern view that the brain (and by implication the mind) is merely a biological computer. Such a perspective is problematic on a number of levels, but I’m going to set aside my objections for now. The brain processes information, so one can in fact draw parallels with digital computing machines. Of course, biological nervous systems are far more flexible and elegant than computers, and they may plumb layers of reality beyond the reach of silicon chips. But let’s focus on the similarities for the purposes of building a new mental health paradigm.
We are told that “mental illnesses” are brain diseases. But if so, they differ from the kinds of conditions treated by neurologists. Parkinson’s disease, Alzheimer’s dementia, multiple sclerosis, and so on can all be identified by looking at brain tissue. Mental illness cannot. In fact, the difference between neurological and psychiatric conditions is that the former are organic and structural, while the latter have never been shown to be.
Using the “computers of flesh” analogy, this suggests that true neurological brain disorders are problems of hardware, whereas psychiatric issues derive from software. You treat hardware problems with material interventions: replace components, clean connections, rebuild the material structure. You treat software problems by correcting processing errors. In other words, treat brain diseases with medications and surgery, but treat purely mental conditions by training people to think and behave differently.
To make the analogy more concrete: If a computer screen won’t turn on, you might need to repair a switch. But if it shows your child pornographic images, you need to install programming to block offensive websites. The former is a material intervention, whereas the latter changes information processing. The first would be analogous to giving dopamine precursors to a Parkinson’s patient, who suffers from faulty basal ganglion switches (synapses). The second would be like teaching mindfulness meditation to quiet disturbed thinking.
Behavioral derangements aren’t organic diseases, they are processing errors. The word “illness” might not be entirely inappropriate, but if we use the term we need to be very clear that it refers to something that is best approached by training people rather than gumming up synapses with chemicals. Naturally, drugs might be helpful in calming acute crises, but we need to recognize that they are not treating the underlying problem, which is informational and not structural. Software, not hardware.
The idea that a computing device can be functioning normally on a physical level, but causing problems on an informational one makes perfect sense to anyone comfortable with digital computers. So why can’t we accept this possibility in the case of human minds? Why is it insufficient to ascribe behavioral problems to perceptual and cognitive errors? Why do we insist on invoking organic pathology to explain variance?
Obviously, building mental health would be easier if it could be done with pills. But whether we speak of a recognized “mental illness” or a socially acceptable insanity like insatiable greed, changing behavior patterns is not that simple. It takes work and it takes responsibility. We have become so reluctant to blame people for their problems, we have forgotten that human life is ultimately about personal choice. With effort and wise guidance, we can learn to choose thoughts and behaviors. Yes, it is very hard work. It takes years and it takes mentoring. But remember the common name for a change in information processing: we call it learning. It’s accomplished with time and effort. To date, no pill has been invented that can sidestep this reality.
I’m fully aware that this distinction between software and hardware is overly simplified. The material brain and the informational mind interact continuously. There are probably subtle inherited synaptic tendencies that make some people more susceptible to, for instance, depression. But this still doesn’t imply that the depression is due to an organic flaw. Under the right circumstances, that same brain might be capable of creative success far beyond the reach of those with less sensitive circuitry. The same propensity that causes depression could well cause great happiness, with the proper training.
In the last post I made the point that many so-called psychotic conditions would have been applauded in earlier cultures, whereas they get medicated and hospitalized in our own. A brain might be genetically wired to enter such expanded mind states more readily than average, but this is only a problem if the culture makes it one. It is not an organic disease.
The view of mental problems as programming errors is far more hopeful than the disease model. The sufferers retain the privilege of possessing normal brains, but know they have work to do. And don’t we all?