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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.

SPSP conference: the cheat-sheet

So, you didn’t make it to the Society for Personality and Social Psychology (SPSP) annual conference in San Antonio? Have no fear, I forked out loads of money to go…Why, I don’t know. I was the only journalist there. Anyway, as a result, you can use my SPSP cheat-sheet to pretend you were there. Easy!

The main reason I went, besides the fact that I’m a spendthrift idiot, was to see a pre-conference symposium on consciousness, organized by Roy Baumeister (pictured below left) and Kathleen Vohs. What interested me about the event was that John Bargh was speaking there.
Bargh and Baumeister have had an interesting argument going on for a few years about the roles of the conscious and the unconscious in the human mind. Bargh is the most famous proponent of the idea that most human activity is carried out by the unconscious, that a lot of the time our minds are unconsciously reacting to stimuli according to subliminal priming cues – something he and others have shown with a lot of priming experiments, where subjects are ‘primed’ with subliminal images or words, which then unconsciously affects their behaviour and motivation. Two years ago, Bargh told me in an
interview that he thought 99% of human behaviour was accounted for by the unconscious.

Baumeister and Vohs, meanwhile, have insisted that consciousness has an important role to play, that we do in some sense ‘choose’ how to act, we can choose to control our automatic impulses, and therefore we can be held responsible for what we do.
This is obviously a fairly important debate, not just for my own work, on the relevance of ancient philosophy to modern life, but also for our culture, and our whole sense of ourselves as free agents capable of moral choice.

Well, I was expecting fireworks but alas it turned out to be a bit of a damp squib. Sadly (or maybe happily), Baumeister and Bargh seem to have arrived at something like a common ground, in which the important roles of both the conscious and the unconscious is acknowledged. The conscious, they now seem to agree, can do some things which the unconscious can’t. It can do sequential reasoning – logic, maths, sentences. “The unconscious can’t do maths”, as Baumeister put it.

It can also take other people’s perspectives, so it’s important for negotiations. It’s important for story-telling, narratives, and some forms of causal reasoning. It’s important as a time-traveller – going back in the past, projecting into the future, and thereby making plans. And our consciousness is the controller, at least sometimes. It can over-ride automatic responses, it can manage self-presentation, it can modify our impulses to fit in with our evolving culture and get on with other people and other tribes.

So there are all sorts of things the conscious mind does, which we become much worse at when we’re under ‘cognitive load’. Baumeister, Vohs and Masicampo presented
a new paper they have forthcoming, which reviews several studies and ‘proves’ what exactly conscious thoughts do for us.
There are other things the conscious mind does less well. It’s not good for rapid information processing or threat response. It’s not good for bodily responses – in fact, thinking too consciously about a shot can make a sportsman ‘choke’ under pressure. And, as Bargh pointed out, the unconscious plays an important supporting role. For example, you know those moments when you’re driving, for example, and day-dreaming about the past or the future, then you realize you have just been on auto-pilot, as it were – steering your way around the city unconsciously. Well, that’s part of the role of the unconscious. It can be your auto-pilot, freeing up your conscious mind to roam through time and space.
So Bargh and Baumeister had a big love-in, much to my disappointment. But I guess it’s good news for humanity if they are getting on. It suggests an optimistic vision of the human psyche, in which the unconscious and the conscious aren’t at war with each other – as they were in Freud’s theory, for example. Instead, they support each other and complement each other. Bargh gave the metaphor of a dolphin, swimming beneath the surface, and occasionally jumping out of the water into our view.

Having proven to most people’s satisfaction that consciousness does, actually, play a role in human behaviour, Baumeister went on to consider the purpose of consciousness. He concluded that its role was
‘for facilitating social and cultural interactions’. It gave us the biological advantage of enabling us to plan, time travel, regulate our behaviour to fit with evolving cultural norms, record our cultural insights to share them across generations, and negotiate with other people and tribes. So it gave us an advantage over other animals, enabling us to become the dominant species on Earth.

That all makes sense – but I wonder if consciousness doesn’t do more than this, as well. Is the purpose of consciousness really just to help us reproduce and survive better? It seems a very complicated tool for such a basic job. And is our consciousness only for communication? Aren’t there, perhaps, moments of peak consciousness that we can’t communicate to others? I suppose what I’m suggesting is that consciousness seems a bit more mysterious than simply helping us fight, fuck and negotiate better. Its powers seem excess to those challenges. It enables us to contemplate the universe, to contemplate God himself. What’s the evolutionary point of that? But perhaps I am being a ‘mysterion’. I suppose one could explain consciousness purely in terms of evolutionary adaptation.

Another speaker at the pre-conference on consciousness, the psychologist Jonathan Schooler, did go further in his explanation of consciousness, suggesting it might actually play a role in the nature of the universe. This didn’t go down well with the philosopher Patricia Churchland, who was in the audience, and who accused Schooler of ‘Hegelian idealism’. Ouch! Churchland herself seemed a bit up in the clouds, however. She gave a rather rambling talk, which started off by rejecting the idea that consciousness had no role to play – when in fact, she suggested, we can modify our behaviour by conscious training. But then she seemed to come full circle, suggesting that actually our behaviour is determined by neuro-chemical activity, so we can’t be held responsible for what we do, and the legal system is really a convenient fiction for the benefit of society.

It seems to me that we still haven’t really got over the problem of dualism. On the one hand, it seems ridiculous to suggest there is something called ‘spirit’ or ‘soul’ which can hover in a cloud of free will above the determined rules of the material realm. On the other hand, it does seem that there is this thing called consciousness, which can make free moral choices. How the hell does that happen? Not an easy one to answer. Philosophers and psychologists hate to even suggest there is a ‘homonculus’ sitting inside us making choices and steering us. And yet there is this thing, called the self, which coordinates various mechanisms and information channels in the brain. Isn’t there?

The Stoics thought that conscious awareness was a form of divine matter, which they called the Logos. The more you trained yourself, the more brightly the fire of your inner Logos burned. In the modern era, Baumeister has suggested that agency is some sort of natural resource, which you can use up, but which you can also make more of. The more you exercise self-control, he has suggested, the more you develop your
‘moral muscle’, and your ability to control your impulses and make more free decisions. This is a very hip field in psychology, if the SPSP conference is anything to go by. There were several talks and panels on self-control, self-regulation, and ego depletion – a term associated with Baumeister, regarding how our resources of self-control can get used up and depleted. It’s a very ‘hot’ term – I walked past one young delegate complaining to her friend ‘oh my God, I was out so late last night. I’m totally depleted!’
Another hot topic at the conference was mindfulness. There were many, many talks about mindfuless training, loving kindness meditation, breath meditations, the effects of meditation on the brain, the fact that meditation increases the production of an enzyme called telomarese which is important in cell repair, the role of loving kindness meditation on vagal tone (vagal, not vaginal) and so on, and so on. Wow, western psychologists are so into Buddhism at the moment. No one mentioned Stoicism, sadly – although there were several panels on self-control and cognitive re-appraisal which did draw on Stoic ideas…but apparently the psychologists weren’t aware of the Stoic connection, or didn’t see fit to mention it. Instead one was struck by a great tsunami of Indian and Tibetan buddhism. We must bow to our Asian conquerors! Oh well. Still – mindfulness. A good idea, right? Another example of training our conscious mind and using it to change our thinking and behaviour. We saw some results from the impressive Shamatha Project, which has studied the effects of taking a multi-weak meditation retreat. Looks very interesting – would love to go on a retreat myself this year.

Another theme which interested me was the emphasis on field experiments, and taking social psychology beyond the lab and beyond undergraduate experiment subjects. Apparently, 80% of social psychology experiments involve undergrads being tested out in laboratories. That’s going to skew the results. I saw an interesting talk by
Wilhelm Hofmann of the University of Chicago, that studied people’s self-control in real life situations, using in vivo technology like iphone apps and bleepers to see what people were doing, what desires they were feeling, and how successfully they were controlling those desires. But, as I said in a question, we can’t tell to what extent the act of observing the experiment subjects and asking them to record their desires is actually changing their behaviour, making them more conscious, mindful and self-controlled. I would think it is.

Finally, there were still a fair amount of happiness / wellbeing / positive psychology studies, though not as many as I would have imagined. There was no mention, for example, of Martin Seligman’s $125 million Comprehensive Soldier Fitness programme for the US Pentagon, even though that seems to me to be one of the major events in contemporary psychology. There were some interesting panels and talks on measuring wellbeing, on regional differences in wellbeing and life satisfaction (two interesting facts: Utah is the happiest state, and New York is one of the most neurotic states, despite or because of the fact it has the highest density of psychologists and psychiatrists). There were quite a few talks and panels on mind training techniques (mindfulness, keeping a journal, doing acts of kindness, changing your perspective and so on). But there were also signs of a backlash – one of
the most interesting talks, for me, was by Iris Mauss, on how people who put a higher premium on happiness tend actually to be less happy, and more prone to depression. I’ll hopefully write more on that study in the coming days.

All in all, it was a fascinating conference, I was impressed with the quality of work on offer, and by the general standard and vibrancy of American experimental psychology. Attending my first ever psychology conference made me realize how much philosophy could learn from experimental psychology – but it also made me think that experimental psychology still needs the help of philosophy, to protect it from over-hasty generalizations and poor semantic definitions. Nowhere is that clearer than in the psychology of happiness and eudaimonia.