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The Concept of “Mental Illness”

In 2.3 mental illness, taken literally, was considered an untenable concept. It can be made tenable by indicating that it means illness, the manifestations of which are seen as disorders and aberrations in psychical and social functioning. In common usage the term mental illness is applicable to psychoses and more or less synonymous to madness. In English-speaking countries the term seems used more broadly and is more a part of everyday language than in the Netherlands. Therefore perhaps it would be better to avoid the term. The most pragmatic solution would be to replace it with “psychiatric disorder” which indeed has been done as much as possible in this book. The term psychiatric disorder is synonymous with “mental illness,” and more importantly, with the term “mental disorder” used by the DSM-III.*

The risk inherent in the term psychiatric disorder is that it will be perceived as all with which psychiatrists concern themselves. That would legitimize every expansion of psychiatry a priori. One should be aware of this risk precisely because it is the reason the problem of defining mental illness is posed in the first place. (See Chapter II, 3.5.)

Using the term psychiatric disorder has additional advantages. In the first place, it does not reflect a dualistic view of man, as does the term mental illness. Secondly, the word disorder suggests that the diseases so categorized are not identical to bodily diseases but rather differ from them in important aspects. Thirdly, it reflects that the subdivision of diseases among the various branches of medicine in fact does not meet logically and methodologically consistent criteria, no matter how much one would wish it to. Van Nieuwenhuizen, who was many years chairman of the Central Committee for the Training of Medical Specialists in the Netherlands, and therefore particularly expert in this field, during his retirement speech stated among other things: “The subdivision of specialties is one of the most irrational in the world.”

The term psychiatric disorder includes several very different disorders, also in comparison to each other. A large part of them, in particular the neuroses, are fairly generally presumed to correspond to no clear physical aberrations. In a different part, such as the symptomatic and organic psychoses, the dementias, and deliriums, the relevance of an organic disorder is incontrovertible. Regarding yet another part, as the many psychoses and in particular schizophrenia, the issue of the existence of underlying organic disorders is the subject of hot debate. So the three groups listed in 2.3 are all amply represented.

When a relevant and demonstrable organic aberration is present in a psychiatric disorder whether such a disease belongs in psychiatry can at most be doubted, and it can be posited, as does Szasz, that it should be included in neurology. There is no conflict about the disease status of such disorders. The reason that such disorders are included in psychiatry seems to be related to the way in which care and treatment are organized rather than to the illness itself. For instance, when someone with psychiatric problems is discovered to have a cerebral tumor, the primary treatment will be neurological or neurosurgical. Remaining behavioral disorders after completion of such treatment will be referred to psychiatry even though they initially resulted from the tumor and its treatment. So psychiatric disorders are those that express themselves mainly in experience and behavior regardless of their causes. Psychiatry scarcely utilizes the techniques and methods of somatic specialties, respective of medical examination as well as treatment. The boundaries are indistinct and determined more by daily practice, experience, and sometimes local conditions, in short, by pragmatic arguments rather than principles. The significance of the link between psychiatric disorders and organic aberration will be further discussed in 2.5.

The controversy about whether or not psychiatric disorders constitute diseases regards those disorders for which no relevant organic aberration can be demonstrated. An important consideration is that people with such disorders can be called ill due to the factors of suffering, dysfunction, and abnormality. That third factor, abnormality, cannot be determined other than in terms of experience and behavior. This means that the real basis of these disorders can be determined much less objectively, in any case to the extent that a degree of objectivity as required by the physical sciences cannot be found here. Although physicochemical events are in principle no more real than events, circumstances, and human actions in general, psychiatry in fact does not base itself on those actions and events in themselves, but on psychologically understood complexes which include the action as well as its context and its quality. The entire framework in which the action takes place, or, in any case, in which the action is significant, is important. An example borrowed from Kraus’s textbook is a respectable housewife who steps totally nude out of the window of her ground floor bedroom to buy strawberries from a passing vendor. Such an act would be considered a disorder of judgment, unless, for instance, she were an actress being filmed for a movie. This example illustrates a difference from when a bodily aberration has been found, albeit a gradual, not principal difference. A bodily aberration provides us with enough information in itself without knowledge of the context (see also 3.3). This difference is related to the structure and organization of our knowledge and familiarity with reality.

Jaspers noted already in 1923 that the idea of illness is always linked to a value judgment (Wertbegriff) in addition to a principle of normality (Durchschnittsbegriff). Positing that the physician “um gar nichts klüger(ist), wenn es im Allgemeinen heisst, irgend etwas sei krank,” [“is generally no wiser than that someone is ill”] he continues that physicians have sought and concerned themselves with “eine Fülle von Seins- und Geschehensbegriffen” [“an abundance of concepts about symptoms and processes of illness”]: “Weil die Fragestellung ursprünglich aus dem allgemeinen Wertbegriff kam und fortdauernd durch die therapeutischen Aufgaben des mediziners mit ihm verknüpft bleibt, nennt er alle diese von ihm geschaffenen Seinsbegriffe, aus denen die Wertung so gut wie ausgeschaltet is, doch Krankheiten.” [“While the original issue was whether the general value judgment is not that, through continued therapeutic treatments, the physician remains in contact with the patient, calls all matters he encounters signs of illness, and so automatically considers everyone who comes to him as ill”]. Hereby Jaspers notes the negative value judgment as essential while the process of redefining illness as an ontological process is of lesser concern. When redefining, the value judgment was increasingly forgotten and that which was describable as a fact and a process increasingly became the focus of attention. It seems to me that now, sixty years later, this process has progressed yet further. The description of illness has been removed even farther from the Wertbegriff which it originally was and factually still is. Therefore disease seems to be increasingly considered a fact, a factor in reality, rather than a concept that is intended to conceptualize certain ominous, unwanted events in life.

Two trends have been notable for some time. One is that disease as a Wertbegriff began to regain interest. Occasionally this happened indirectly, namely by describing health as a Wertbegriff (for instance, in the WHO definition, see Chapter II, 3.3). The consequence was that health became more than the absence of disease because disease remained defined as a fact. Another expression of this trend in the Netherlands was Querido’s noting that when medicine concerns itself only with the factuality of illness, in many ways it falls short in practice. Since then, the attitude and role of the physician, particularly that of the family doctor, has been a constant subject of debate. Those aspects of being ill that were removed from the definition of illness in the biomedical disease concept came under scrutiny. The other trend was to remove value judgments farther and more consistently from the disease concept in an effort to achieve value-free, objective medicine. Szasz’s description of illness as a physicochemical disorder fits into this trend. Psychiatric disorders, as disorders that fit poorly or not at all into a biomedical disease concept, led to a great deal of controversy in this trend as to whether the disease concept was applicable to them at all. Therefore other conceptualizations were sought in which the facts could be accommodated more satisfactorily than in the biomedical disease concept. The point is that gradually it is becoming clearer that several diseases can have no more than a controversial status inside the biomedical disease concept because the expected organic aberrations cannot be demonstrated. So we are faced with a choice: either declaring these uncertain illnesses to be non-illnesses, or realizing that illness originally was and in fact still is a “Wertberiff,” with the consequence that a disease concept must be found which accommodates this value concept.

Medicine that is focused on physical science can deal with facts and processes but shuns values. For a while there was a euphoric belief not only in value-free science but also in value-free medicine, and even in value-free psychiatry. Gradually it became clear that this illusion could be upheld only when certain values are reified and considered solid laws, as a prioris instead of values. Bichat expressed it thus at the beginning of the nineteenth century, “La vie est l’ensemble des forces, qui résistent à la mort.” [Life is the collection of powers that resist death.] This dictum was often a practical hypothesis quite reconcilable with the wishes of patients. It turned into a law that required medicine to postpone death as long as possible at every cost. Therefore expressing doubt about whether this dictum was always everywhere the right course became nearly taboo even when the enormously expanded development of medical-technical equipment led to a demand for quality of survival. The value and significance of death were denied as well as the value and significance of being ill. Put differently, because death was viewed as ominous and living longer as valuable, this value judgment was turned into an unquestionable law. It seems to me that part of the lack of understanding for and the tremendous resistance against abortion, euthanasia, and suicide, precisely among physicians, must be understood this way. To physicians, who prolong life at every cost, it is incomprehensible that the patient does not always want that.

In the case of psychiatric disorders, not only this central problem of illness as a value-judgment as opposed to illness as a concept of being arises. Also some other aspects of psychiatric disorders, conceptualized as illnesses, pose problems that are important in this respect:
  • When certain forms of behavior and experience are viewed as disease it is fairly impossible to not implicitly or explicitly reflect social norms. In this matter the point is not the line between illness and non-illness, but that in the realm of illness, the manifestations of psychiatric disorders can be described as facts but are in fact not uncommonly violations of social norms or normative behavior. To quote Szasz, “Whenever we try to give a definition of what mental health is, we simply state our preference for a certain type of cultural, social, and ethical order.”
  • It is impossible to draw clear lines between what is considered a manifestation of illness and what is not. This problem might be partly solved by drawing pragmatic lines between normal and pathological. Partly the problem goes deeper, because the lines change when different models are maintained. Precisely in psychiatry there is a rather large number of models in which these lines are drawn differently as well as models in which no lines can be discerned. They conflict with models in which the concepts of health and disease figure prominently.
  • A problem which is closely associated with the one above is the near impossibility of defining normality.
  • In somatic medicine, seeking the causes of disease has been quite fruitful. Contrarily, in psychiatry, such a way of looking at disease must be supplemented at least with the motives which are relevant to the experience and behavior which are interpreted as a syndrome. Furthermore, a look might be taken at what the person is trying to express by his syndrome, in other words, the communicative meaning that the syndrome might have. And finally, the purpose (Aristotle’s “final cause” according to Grenander ) which the syndrome might have for the person might be examined.
  • In the humanities, and so also in psychiatry, account must be taken of the influence exerted by the examiner, his methods, and his instruments, on the object of examination.
These five problems underline the dilemma that was already posed by the conceptualization of disease as “Wertbegriff” being inescapable in psychiatric disorders. The dilemma itself can be solved only by making a choice. This choice can be expressed thus: either disease is again conceptualized as a value judgment, which amounts to a biopsychosocial disease concept or something similar, or the attempts that have already been made to define disease as anchored in objective reality according to the biomedical disease concept are followed. If the latter is chosen, it must be accepted that all sorts of situations and processes that were considered part of the realm of disease will be excluded from that realm in order to make the definition applicable. It will be necessary to pretend that illness is objectively present in reality and ignore that “the medical enterprise is from its inception value-loaded.”

The consequences of this choice are extensive. Below they will be examined by systematically comparing the biomedical and the biopsychosocial disease concepts. Although the significance of such conceptualizations for the future of medicine must not be exaggerated, the choice between these two concepts will be of influence. Its influence will be limited firstly because all sorts of factors will remain excluded from the conceptualization, and secondly, because the biomedical concept of disease in the various somatic branches of medicine has proved highly efficacious and will remain so, and so will remain, in that context, a quite tenable (sub-) concept. Briefly summarizing, the direction in which this influence will take medicine could be sketched as follows:
  • In the case of the biomedical model medicine will continue to develop technologically, limited only by the boundaries of physical science and the budget available for expansion. Human bodies will continue to be manipulated in increasingly more perfect technical ways. The prolongation of life at all costs will be countered only by ever more iatrogenic causes of death. Disease, as a fact, will increasingly influence the social decisions that are made about people. The people making those decisions will be the ones exclusively qualified to assess disease: physicians.
  • In the case of the biopsychosocial model, technological development will be limited not only by budgets but also by what people wish to have happen to them when they are ill. In this case the person will be treated not as a body but as a person which may reduce the so-called heroics, but also iatrogenic complications. Significantly fewer social decisions will be made about people regarding their medical conditions. Individuals themselves and only they will have final authority over their lives.
Szasz clearly chooses the biomedical disease concept and thus the first alternative. It seems to me that the biomedical disease concept may to a certain extent be appropriate for the body and (bodily) disease, but that the true task of medicine is to offer people help when they are ill, not necessarily with maximal technical perfection, but in a humane way. This leads me to choose disease as a “Wertbegriff” and a biopsychosocial disease concept.

I wish to point out that in this aspect Szasz’s choice leads to an effect which is diametrically opposed what he himself advocates. Respect for man and his dignity and freedom in my opinion require us to choose a biopsychosocial disease concept, and in his opinion a biomedical concept. Regarding Szasz’s views on who psychiatric patients are from a biomedical point of view, I will show in chapter VI, section 4, that Szasz’s position is untenable.

*The DSM-III was the current edition at the time this book was written. At the time of the translation, the current edition is the DSM-IV-TR, which still uses the term “mental disorder.” – translator
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