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.