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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.

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.

CBT, lost in the Moral Maze

Radio 4’s Moral Maze this week looked at the government’s expansion of Cognitive Behavioural Therapy (CBT), and at a new report from Lord Richard Layard of the LSE (the principal arranger of the government’s embrace of CBT), which warns that local and national governments are failing to honour the spending commitments they made to CBT.

I personally think that the expansion of CBT is one of the major achievements of the last five years (God knows there haven’t been that many national achievements during that time). Finally, we’re taking mental health seriously. Finally, we’ve found a therapy which works for the most common emotional disorders. And finally we’re putting in place the people and resources to enable the suffering to get help quickly. But, like most big steps forward, it’s been almost entirely un-celebrated by our media – unnoticed even – except by a few angry psychoanalysts who are indignant that CBT should have got so much funding and their own therapy so little.

So I’m disconcerted that, on one of the rare occasions that the government’s support for CBT was discussed, not one of the panellists (Michael Portillo, Matthew Taylor, Claire Fox and Melanie Phillips) should have felt the need to support it. Not one of them saw the need to defend that Service, and to try and protect its funding. What a missed opportunity. Rather than unpicking it, they should have applauded it.

Instead, the need for a National Mental Health Service was criticised from both right and left. On the right, Michael Portillo thought Richard Layard had massively over-emphasised the number of people who are affected by depression in the UK (6 million, according to David M. Clark, the psychotherapist who is the chief architect of the national CBT strategy). Portillo accused Layard of confusing depression, which is serious and nasty, with unhappiness. Lots of people are unhappy, for lots of reasons – calling it ‘depression’ just serves various ‘powerful lobbies’ (i.e. Big Pharma and the CBT industry), and gives scroungers a free ticket to benefits. If extended into the criminal justice system, it also lets people off the hook for bad deeds. Psychology becomes ‘excuseology’.

On the left, Matthew Taylor of the RSA thought Layard was medicalising unhappiness, and suggested that people might have very good social, economic and political reasons for being unhappy. CBT focuses too much on the ‘inner man’, and not enough on the outer conditions. It puts the blame for any dissatisfaction we might feel firmly on our own shoulders, which is a convenient move for government and the rich.

These concerns and confusions come about partly as a result of CBT’s origins in Greek philosophy, and I think we can clear them up if we replace CBT in its original context.

CBT emerged from Socratic and Stoic ethics, which developed as a form of ‘therapy for the soul’, which everyone could use to take care of themselves and transform their negative emotions. The idea was that you practice philosophy your whole life, both in periods of emotional turmoil (what we might call depression today) and when things are going well. The Greeks, lacking the Diagnostic Statistical Manual (DSM), did not divide emotional disorders into endless categories. They simply recognised emotional suffering – those moments when we become the passive victim of our passions, when they block us from enjoying a ‘good flow of life’. And they offered a way for students to get out of such situations, by learning how to examine their unconscious beliefs and values, and to change them.

CBT emerged from Socratic ethics, which taught people to 'take care of their souls'

As for  the ‘medicalisation’ of ethics and emotions, that goes all the way back to the Greeks too. They called negative emotions ‘passions’, from the Greek pathe, meaning suffering or sickness. They often compared the philosopher to the physician, and called philosophy a ‘medical art for the soul’ (as Cicero put it). So the idea that the unhappy are also unwell is a very old one. So is the idea that the morally bad are, in fact, deluded and sick – that’s what Seneca, Plato, Marcus Aurelius and others argued. It is no easy thing to separate these categories, as the Anders Breivik case shows. Of course Breivik should be held accountable. But of course, he is also fucked up – shooting 65 teenagers is fairly strong proof of being mentally ill, to my mind.

When we go back to the ancient Greek roots of CBT, it clears up various issues.

First, the question of how much to concentrate on the inner man versus the outer conditions. We see that CBT emerged particularly from Stoic philosophy, which focuses entirely on the inner man rather than outer conditions. The philosopher, according to the Stoics, is so mentally resilient that they can be happy in any situation, even while being tortured. They make their soul an ‘inner citadel’ against their culture’s toxic values. CBT inherits this same highly individualistic focus – change your self and make it an inner citadel against the fucked-up-ness of your society.

We can (and should) disagree with this intense focus on the inner man, and point to the strong influence of environmental factors like poverty on mental health. At the same time, the Stoics were right that all humans have some capacity to control our emotions, and helping people develop this capacity gives them the strength and autonomy to change their environment and change their society.

So Stoicism / CBT doesn’t have to be some sort of neo-liberal atomised self-help. If you look at Aristotelian philosophy, for example, it shares the Socratic principles of Stoicism / CBT (i.e. the idea we can use our reason to change ourselves and achieve flourishing) but it also recognises that our society and culture plays a big part in our well-being, and that as citizens we should take care of both ourselves and our society. We should balance the inner work of CBT with the outer work of changing our society. I think Layard recognises that. He’s not saying we should focus entirely on the inner man, only that we have ignored that factor for far too long in western politics. That’s a wise realisation for a Fabian in his 70s to reach.

Secondly, the question of personal responsibility.  Does CBT excuse people from their moral behaviour? Or does it put too much responsibility on our frail shoulders? Again, going back to the Greeks helps. They didn’t argue that we are all born free, rational, sovereign agents. But they argued that the vast majority of us can become slightly more free, slightly more self-aware, slightly more self-controlled, if we practice philosophy for several years. Autonomy is an exercise, and like other forms of exercise, we become better at it through practice.

But the first step is to take responsibility for our own beliefs and actions – not blame them on our environment, on our parents or friends or the economy or the weather. The economy may be terrible, and you being unemployed will almost certainly affect your mood. That’s not your fault. But how you think about your situation is going to affect your feelings. You can make that shitty situation a lot worse, if you want, or you can cope with it in a wiser and more effective way – not beating yourself up, while also looking for opportunities to get out of the situation.

Since my book has come out, I’m often asked by worried parents if their offspring’s mental / emotional problems are their fault. They are often relieved to hear about CBT, as an alternative to the old Freudian line that ‘they fuck you up your mum and dad’. Well, actually, you might very well have been fucked up by your mum and dad. They might very well have indoctrinated you in the thoughts and habits that are making you miserable today. However, these are now your thoughts and habits. Your mother and father aren’t standing over you forcing you to harm yourself. You’re doing it to yourself. As the great Bill Knaus says in my book, what happens to us is not necessarily our fault. But how we think about it is our responsibility. Don’t be a masochist. Don’t beat yourself up and then blame it on someone else.

Of course, some people are born into much harder situations than others. Some people grow up in environments that are constantly pushing them to depression or vice. Others grow up in environments that are constantly pushing them to flourish. That’s unfair, and we should do what we can to correct that. Part of that is giving people the tools to be resilient to their environment, to resist its bad influences and find the good influences.

Finally, the question of the division between Depression and unhappiness. Are we medicalising the entire society and pathologising perfectly normal things like unhappiness, shyness or anxiety? Again, let’s go back to the Greeks. Without the benefit of the Diagnostic Statistical Manual (DSM), the Greeks didn’t recognise particular emotional disorders, nor did they try to ghettoise them from ‘normal human experience’. Instead, they saw emotional suffering as on a continuum, from the very distressed to the quite distressed to the well to the flourishing. And they recognised that philosophy could and should help people all along this continuum.

Today, most people still don’t seek help for emotional problems, because they’re worried about ‘making a fuss’, or about admitting that they’re somehow officially broken or sick. Might it appear on their permanent NHS record? What if their employer found out, or their friends, or their family? Would they lose respect, authority or even their freedom as a result? And besides, isn’t it narcissistic to worry about their feelings? Who the hell is happy in this world anyway? And so most people do nothing to take care of themselves. They carry on veering through life, like a car with a flat tyre.

Philosophy, as Socrates insisted, helps us learn how to take care of ourselves. That isn’t selfish. It’s responsible. If we’re not taking care of ourselves, we’re probably affecting the people around us, and we’re also probably not engaging as effectively with our society as we could be. CBT is a form of therapeutic philosophy for people in serious distress – that could mean a particularly stressful period of your life, or a bout of depression, or panic attacks, and so on. Such moments affect many of us – perhaps 25%, perhaps as much as 50% – so go get some help, either from a GP, or from a CBT book, or from my book! Learn how to take care of yourself, how to steer yourself.

The Greeks thought philosophy should be available for everyone. I agree. I think everyone should be introduced to it, to learn how to take care of themselves. However, there is a difference to helping people in a serious emotional crisis, as CBT does, and helping people not in a serious crisis, as Positive Psychology tries to do. The latter group should not be told how to be happy. They can be taught some of the basics – how emotions arise, how we can change them – while also being encouraged to explore the different ethical visions of the good life that we can use these basics for.

One of the panellists, Michael Portillo, was particularly scornful of the fact we diagnose people with depression by asking them how they feel. People could lie, he pointed out. Well, that’s true, and no doubt many people do. But how else can we diagnose depression? How can we know how someone is feeling, except by asking them?

Aaron Beck, the pioneer of CBT, took ideas and techniques from ancient philosophy, and then married them to scientific empiricism. He invented the Beck Depression Inventory, which measures how depressed a person is by asking them, for example, how often they think about killing themselves. Now of course that sort of diagnostic technique can be fiddled by the unscrupulous. And of course, it is a bit simplistic. But it’s also a useful way of discovering if a therapy is really having any obvious effect. If a person, at the beginning of a therapy, says they’re extremely unhappy and think about killing themselves often, and at the end of the therapy they say they’re fairly happy and don’t think about killing themselves ever, then that’s a measurable success, isn’t it? And crucially, it’s only through such measurements that governments have been persuaded to support CBT. If it wasn’t for such measurements, far fewer people would be reached or helped by CBT.

I, like Portillo, am wary of the power of Big Pharma, and of a world where we have defined the entire population as in need of chemical interventions. But I do, actually, think that, in the words of Albert Ellis, 99% of the world is out of their fucking minds. Including me. We’re all on a continuum of mental health, and I certainly don’t think I am ‘flourishing’. I’m pretty well, but I’m self-aware enough to recognise I have a long way to go yet. Philosophy, no doubt, will help me on my journey.

Anyway, this is all a rather roundabout way of saying I think it is a very good thing that we now have a National Mental Health service, and that CBT has become available to ordinary people, rather than just the rich. So many of my friends have suffered from mental health problems at one time or another – most of them in quiet desperation. A lot of them could be really helped by some therapy, whether through the NHS, or through DIY therapy like reading a CBT book. That’s not narcissistic. It’s responsible. It helps them contribute to their society. Please can policy makers and opinion-influencers celebrate our new National Mental Health Service, rather than attacking it?