Introduction
Mental health is something that we must face at some point in our lives. Either we or someone we know will suffer from a mental illness. Being mentally healthy is a continuous, effortful, attentive approach to our wellbeing as our lives change during our life. How we understand what mental illness is, is fundamentally important to how we approach it in our treatments. Our value for wellbeing is necessary for us to have a motivation to pull ourselves out of the clutches of mental illness in all of its forms.
First, I will go through the philosophical underpinnings of what mental illness is with a close inspection of Thomas Szasz's The Myth of Mental Illness (1960) paper. Here, he discusses how the concept of mental illness is distinct from physical illness, the terms we use to describe mental illness needing closer examination, what the indication of illness would be, and the role of professional intervention. He concludes that mental illness does not exist and we really distract ourselves from the truth of problems of living when looking at the world through that paradigm.
Second, I look at a discussion between Thomas Szasz and Albert Ellis, both leading psychologists in the field at the time, in an essay by Robert Spillane (2018). Here, Spillane discusses problems of the DSM, what the definition of mental illness is, the difference between scientific and social facts, Szasz’s conceptualization of the mind, and the difference between Szasz and Ellis’ form of psychotherapy. Even though they have different approaches, Szasz and Ellis’ methods can be combined in response to the problems of living that Szasz identifies in his initial paper.
Thirdly, I explore a practical application of treating problems of living today with three case studies in therapeutic communities: substance abuse, personality disorders, and schizophrenia. We find in all three cases that the therapeutic community methodology is more efficacious than control groups in treating the illness and increasing the wellbeing of the patients.
Lastly, I explore an ethical argument looking at the principles of autonomy, non-maleficence, beneficence, utilitarianism, universalizability and justice. My thesis is that the best way for us to move beyond mental illness, as problems of living, is to generalize the model of the therapeutic community to society in general so that everyone has the education and skills to respond to problems of living as they arise instead of delegating these issues to mental health professionals. On all six ethical principles, I have demonstrated that it is the best course of action for every person to learn practices that will help themselves and those around them with the results being a world that proactively prevents mental illness and retroactively treats existing mental health problems.
Part I: The Myth of Mental Illness
In Thomas Szasz’s article The Myth of Mental Illness, he questions whether mental illness exists and argues it does not. He begins by identifying that mental illness is not a physical thing or object and only exists as a theoretical concept. He cautions that when we become familiar with a way of thinking about something theoretically, we can believe it as an objective truth or fact. He traces our tendency to conceptualize and explain ‘happenings’ of events as self-evidence causes with reference to witches, deities, microorganisms and mental illness. Szasz asks what are we asserting when we state that someone is mentally ill and if the usefulness of this concept functions only as a myth. (Szasz 1960, p. 113)
Szasz turns to the origin of mental illness as a way to explain diseases of the brain and not the mind, alluding to the example of syphilis and being intoxicated or delirious, which exhibit disorders of thinking and behaviour. He identifies an assumption within the concept of mental illness, that disorders of thinking and behaviour all have some neurological deficit to be discovered. This view excludes problems people can have in personal needs, their opinions, social issues, and values as reasons for mental illness. (Szasz 1960, p. 113) Szasz states,
“All problems in living are attributed to physicochemical processes which in due time will be discovered by medical research.” (Szasz 1960, p. 113)
Szasz is basically showing how there is an inherent issue in a reductionist view of mental health, that a problem exists if we see behaviours or thoughts being distilled as simply chemical processes.
The conceptual view and perspective that mental illness and other diseases are essentially the same, except that the former affects the brain and manifests as mental symptoms, whereas the latter affects the organs and are manifested in symptoms of the body. Szasz sees two errors in this position. First, a disease of the brain is a neurological defect and not a problem of living. A person’s belief, for example some psychotic or delusional belief that they are a robot, is not something explained by a defect or disease in their nervous system. (Szasz 1960, p. 113)
Epistemology
Secondly, in terms of psychosocial behaviour of communication with oneself and the world we live in, as a form of neurological functioning, is epistemological. (Szasz 1960, p. 113-4) Essentially, how we come to know things, knowledge about myself and the world, can be explained neurologically. However, issues in the content of that knowledge are not reducible to neurological problems but are issues of comprehension like ignorance or lacking understanding. Assuming there is no neurological deficit, the epistemological problems of comprehension can be resolved through learning. If someone has a misunderstanding of themselves or how they relate to the world, exploring an existential discussion can reveal a solution that was created from a misunderstanding, not a brain issue.
Assuming observations or reasoning are not in error, problems may occur in how one organizes or expresses their knowledge. Specifically, an error can be found in how one makes
“a symmetrical dualism between mental and physical (or bodily) symptoms, a dualism which is merely a habit of speech and to which no known observations can be found to correspond.” (Szasz 1960, p. 114)
Basically, because the concept of mental illness comes from a physical disease model, we enter into problems in the application of the concept of mental illness as we try to understand it through a physical conceptual framework. People will actually confuse themselves more if they attempt to understand issues of themselves and relation to the world using a physicalist conceptual framework, ‘I am upset because my neurology is off,’ when they could find solutions to their problems if they perceived things without reference to their brain, ‘I am upset because I did not foresee the outcome of my decision and my expectations need adjustment.’
Signs and Symptoms
Szasz exemplifies this by distinguishing between signs and symptoms. The physical signs of a fever and symptoms of pain are different from the mental symptoms of a person’s communication with themselves, others, and the world. If we observe the statement “X is a symptom of a mental illness,” it makes sense only when a judgment is imposed. Szasz states,
“The judgment entails, moreover, a covert comparison or matching of the patient’s ideas, concepts, or beliefs with those of the observer and the society in which they live. The notion of mental symptom is therefore inextricably tied to the social (including ethical) context in which it is made in much the same way as the notion of the bodily symptom is tied to an anatomical and genetic context.” (Szasz 1960, p. 114)
When we have a physical problem, we can use the prototype of a healthy body as a reference point to know that an issue is present. If we see someone with a rash, we know that is a problem because healthy body’s are not supposed to be discoloured in this way. The judgment is made by comparing a healthy body to the present case of an unhealthy one. In terms of determining a symptom of mental illness, specifically, one’s understanding of themselves, others and the world, can only be judged with reference to our current sociocultural framework.
Critical Thought:
However, the judgment from others in determining a person is in the midst of mental illness excludes the individual's awareness that they have a problem. It is not true that the comparison to a sociocultural standard is necessary to determine if one is mentally healthy. In Obsessive Compulsive disorder, where a person would check the locks 15 - 20 times because of unrealistic anxiety, assuming no neurological deficit, they can understand and have the awareness that the intrusive thoughts and compulsive behaviour are expressions of a mental illness and seek to change their ways of living.
No other person is necessary to know we have a mental health problem for all mental health problems. Only some mental health conditions would require the observations and awareness of others, communicated to the person in question as a judgment, to determine if they are mentally healthy or not. Our own self-awareness is sufficient to determine if our state of being is healthy. Sometimes the intervention of another may be necessary, but not all the time.
Another issue not covered by Szasz here is that we do not need to be culturally relativists when it comes to mental health. There are factors of the human condition, like distress, dysfunctionality, deviance, and dangerousness that are used to determine abnormality for behaviour. (Nolen-Hoeksema 2020, p. 6) These 4 factors can be independent of a cultural framework to determine if someone’s way of being is healthy or not.
Signs and Symptoms 2
Szasz believes that he shows there is a problem if we conceptualize a symptom of mental illness as a sign of brain disease. The concept of mental illness is unnecessary and misleading if mental illness is meant to signify brain disease for one could skip a step, parsimoniously, and just say they have a brain disease. (Szasz 1960, p. 114) Szasz would be using the scientific principle of Occam's razor here by reducing the amount of assumptions we are making in our explanation. The principle is parsimony, that the simplest explanation is often the best, is important to eliminate unnecessary assumptions and refine down our conceptual framework to only what is necessary.
In its common usage, mental illness is not used to signify one has a brain disease. The difficulty of being alive today is not related to biological survival, but is found in the stress and struggle in the complexities of our social-individual personalities. One of the predominant uses of someone who suffers from a mental illness is really a means to describe a deformity in their personality and a cause of individual disharmony. (Szasz 1960, p. 114)
There is an assumption that in our social interactions an inherent harmony exists and when this harmony is disturbed, it is a sign of mental illness on part of the disturber. Szasz identifies fallacious reasoning here, for the abstraction of mental illness is turned into a cause even though the abstraction of mental illness was an expression for specific types of behaviour. (Szasz 1960, p. 114)
Two fallacies can be drawn from this form of reasoning. First, if we are confusing mental illness as a cause or a way to signify the behaviour, we would be engaged in equivocation, or using the same term for two different meanings. Secondly, one could easily commit the fallacy begging the question or circular reasoning. If we observe someone with disturbing behaviour and state that that is evidence of mental illness, because we see behaviour that is indicative of mental illness, we have assumed the conclusion within the premise.
Indication of Illness
Szasz then moves to ask how we know what kinds of behaviour demonstrates that one has a mental illness. He states, mental illness
“implies deviation from some clearly defined norm.” (Szasz 1960, p. 114)
As stated above in terms of physical illness, the norm is a healthy, normal functioning body stated in physiological terms. The norms applied to mental illness, according to Szasz, are ones we derive from psychosocial, ethical and legal concepts. The way a deviation of a norm of mental health is measured is through these three conceptual frameworks. (Szasz 1960, p. 114) This notion was discussed earlier with reference to the evaluation of abnormal behaviour.
The idea Szasz is criticizing is the remedy for the deviation of the norm of mental health is found in medical measurement. The way the disorder is defined and the remedy for the disorder are of completely different conceptual categories. (Szasz 1960, p. 114) This is another fallacy, the category mistake, in the form of irrelevance and invalidity, we compare ideas that have no actual relationship to each other. It seems absurd to say that some medical intervention would affect non-medical phenomena.
Professional Intervention
Szasz now brings up the question of who defines norms of behaviour and if a deviation has occurred. Either it is the person themselves that knows they are deviating from a norm or some other individual like a relative, partner, legal representative, or society in general determines some person has deviated behaviourally. (Szasz 1960, p. 115)
Psychiatrists can be hired to correct the deviation in someone. Szasz then asks,
“Whose agent is the psychiatrist?” (Szasz 1960, p. 115)
In this context, he means any psychologist that has the socially given power to correct problems of deviation. Szasz is essentially asking, who is the psychologist acting on behalf of: it could be the person themselves or some third party like a relative, school, or workplace, etc. (Szasz 1960, p. 115)
The person and the mental health professional may disagree on what the best course of action is for them, like whether to get divorced or not. If the psychiatrist is an agent of the patient, the patient reserves the right to act as they please in the context of their own life. Szasz states,
“As the patient's agent[…]he must abstain from bringing social or legal force to bear on the patient which would prevent him from putting his beliefs into action. If his contract is with the patient…the psychiatrist[…]may disagree with him or stop his treatment; but he cannot engage others to obstruct the patient's aspirations.” (Szasz 1960, p. 115)
The psychiatrist has an ethical obligation to respect the autonomy and free will of the patient. In this case, the psychiatrist is the agent of the patient and therefore is an extension of the patient's autonomy. It is not up to the psychiatrist to impose their values or remediation trajectory on the patient if they disagree.
If the psychiatrist is working for some third party to help the person, they may not hold the same values, relative to norms, or beliefs, about the nature of correcting the deviation, as those who have hired them. For example, if the psychiatrist is an agent of the court, they cannot state that it is those who made the laws that determine which actions are criminal are insane and not the patient. As an agent of the court, even if the psychiatrist disagrees in legal values, they are obligated to fulfill the duties of determining sanity based on the norms stipulated by the court. (Szasz 1960, p. 115)
Szasz Argument Summary
Mental Illness Argument:
P1 Mental illness identifies deviant behaviour from psychosocial, ethical or legal norms
P2 Deviant behaviour can be judged by the patient, psychiatrist or others
C Correct psychosocial, ethical or legal deviant behaviour through medical action
(Szasz 1960, p. 115)
Szasz Counter Argument:
P1 Medical action is designed for medical deviation
P2 Mental illness is not a medical deviation
C Therefore, medical action cannot help mental illness (Szasz 1960, p. 115)
Szasz concludes that, for example, the application of tranquilizers and drugs generally are an inappropriate solution to a problem in living. (Szasz 1960, p. 115)
Values and Ethics
Szasz now transitions to a discussion of value and ethics. He begins by stating that
“Anything that people do - in contrast to things that happen to them […] takes place in a context of value.” (Szasz 1960, p. 115)
All human activities have an ethical implication or value to them. When certain values within an activity are shared among a large group of people, the value becomes implicit as in the technical, therapeutic discipline of medicine.
The medical and therapeutic system is assumed to be free of an ethical value as shown in medical professionals treating patients with different religious views than themselves. Even when explicitly suppressed, ethics or values are implicit in all human affairs. Any attempt to make medicine neutral in the context of values cannot actually keep them free of values. Szasz identifies moral issues like birth control, abortion, suicide and euthanasia as concrete examples of this point. (Szasz 1960, p. 115)
Szasz stipulates psychiatry as the discipline concerned with problems of living, whereas brain disease would be neurology. All issues within human relations are analyzed, interpreted and ascribed meaning through social and ethical frameworks. A psychiatrist’s socioethical orientation will have an affect on their interpretation of what is wrong with the patient and any desirable direction for change. (Szasz 1960, p. 116)
The view that psychotherapists are responding to problems in living is in contrast to the real and objective view that mental illness is similar to bodily illness. The use of the terms real and objective reflect a perspective that mental illness is similar to a disease entity. Szasz asks why it is not the case that we can ‘catch’ a mental illness in the same way diseases are transmitted and similarly get rid of the illness in the same way. He believes that the evidence of what a mental illness is is really some form of communication that expresses an unacceptable idea. (Szasz 1960, p. 116)
Szasz does identify one major difference between mental illness and bodily illness. He states,
“whereas bodily disease refers to public, physicochemical occurrences, the notion of mental illness is used to codify relatively more private, socio-psychological happenings of which the observer (diagnostician) forms a part. In other words, the psychiatrist does not stand apart from what he observes, but is [...] a "participant observer."” (Szasz 1960, p. 116)
The psychiatrist is committed to their view and society's view of what reality is in the observation and judgment of the patient’s behaviour. There is a relationship between the observer and observed, the psychiatrist and patient within the concept of a mental symptom. This observer/observed relationship necessarily means that moral and values are intimately tied to the judgment of mental illness and symptom identification. (Szasz 1960, p. 116)
The view is that psychotherapy is engaged in a restorative practice for the patient from mental sickness to health. The assumption is that a person’s mental illness is related to their social and interpersonal relations but is not related to issues of values. (Szasz 1960, p. 116) Psychotherapy, however, may be engaged in the elucidation and comparison of goals and values, some contradictory, in an effort to create harmony, realization or a sense of overcoming. (Szasz 1960, p. 117)
Human values are very diverse, the methods used in their realization are vast, and many are unacknowledged which will lead to conflicts in human relations. Human relations are full of stress, strain and disharmony. To create harmony in our lives with others, it requires patience and hard work. Szasz argues that the concept of mental illness obscures attention from the problems in social interactions and acts as a disguise, stating
“instead of calling attention to conflicting human needs, aspirations, and values, the notion of mental illness provides an amoral and impersonal "thing" (an "illness") as an explanation for problems in living.” (Szasz 1960, p. 117)
Problems of Living
Szasz references our past mistake of believing devils and witches being responsible for people’s problems of living. He attests that the belief that mental illness as a problem in getting along with others is the contemporary belief in demonology and witchcraft. He states,
“Mental illness exists or is "real" in exactly the same sense in which witches existed or were "real."” (Szasz 1960, p. 117)
Szasz’s goal is to remove mental illness from the category of illnesses in a paradigm shift towards viewing the phenomena as
“the expression of man’s struggle with the problem of how he should live.” (Szasz 1960, p. 117)
Our self-awareness comes with a burden of understanding that requires further understanding and subsequent action in response. (Szasz 1960, p. 117) Mental illness, just as theological explanations and reliance from suffering, only prevents us from our responsibility for our actions. (Szasz 1960, p. 118)
Szasz concludes that the concept of mental illness is not useful anymore, akin to religious myths like witchcraft, and functions as a social tranquilizer, where mastery of problems is done through symbolic-magical operations. Szass states,
“The notion of mental illness thus serves mainly to obscure the everyday fact that life for most people is a continuous struggle, not for biological survival, but for a "place in the sun," "peace of mind," or some other human value.” (Szasz 1960, p. 118)
Once we overcome our needs for preservation, our awareness of ourselves and the world creates the problem of what to do with ourselves. A belief in the concept of mental illness prevents us from facing this problem and the view of mental health as an absence of mental illness assumes one makes the right choices automatically in the conduct of their lives. This view is reversed, for it is making good choices that produces good mental health. (Szasz 1960, p. 118)
People’s belief in the myth of mental illness leads to the view that if it were not for mental illness or psychopathology, social interactions would be harmonious, satisfying and a stable foundation for the good life. Szasz believes this represents wishful thinking that a universal human happiness can occur
“only at the cost of many men, and not just a few being willing and able to tackle their personal, social, and ethical conflicts.” (Szasz 1960, p. 118)
He finalizes by reminding us that demons, witches, fate or mental illness are not the enemy to be dispelled by a cure. What we have is a problem of living at biological, economic, political and socio- psychological levels of phenomena. Conceptualizing these issues in the form of mental illness distracts from the moral issues within human relations. (Szasz 1960, p. 118)
Part II: Szasz vs Ellis
In Robert Spillane’s (2018) article Mental Illness: Fact or Myth? Revisiting the Debate Between Albert Ellis and Thomas Szasz, he discusses both theoretical approaches for and against the concept of mental illness. To do this he focuses on the classical 1977 public debate between Szasz and Ellis titled Is mental illness a fact or myth?
The DSM
Spillane begins the paper identifying that the Diagnostic and Statistical Manual for Mental Disorders did not develop a definition for mental illness until 1980. He defines mental disorder in the DSM-5 as
“clinical disturbance in an individual’s cognition, emotion, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” (Spillane 2018, p. 344)
He criticizes that the definition relies on the speculative assumption of psychiatrists on the personal conduct and norms of patients. He also identifies that no biological sign used in diagnosis has been discovered for any mental disorder. If a biological sign was found, it would then be considered a brain disorder and not be conceptualized as a mental illness anymore. (Spillane 2018, p. 344) The DSM bases its diagnoses on clinical symptoms that are clustered and not objective data. (Spillane 2018, p. 345)
Scientific vs Social
Ellis distinguished that mental illness may not be a scientific fact but is an unignorable social fact. Szasz, as was discussed earlier, believed that the concept of mental illness is a myth that is mistaken for fact and has logical, as well empirical, issues. Logically, pathologists define illness as something that affects the body, so if the mind is distinct from the body it cannot be ill. The logical impossibility of ‘mental illness’ means that it is also empirically impossible. Attempting to say illness of the mind is illness of the brain it would be a bodily illness and not mental. Therefore, the concept of 'mental illness’ would be self-contradictory. The empirical problem of mental illness has to do with the lack of objective criteria in diagnosis. (Spillane 2018, p. 345)
There is a distinction between a scientific fact that has empirical evidence and a social fact that has effects when a sufficient number of people believe in it. Social facts are simply things that are believed in society even if they do not have an empirical, scientific basis. Ellis believed that mental illness was a social fact because most people believe in it and order their behaviour around it in a confirming way. (Spillane 2018, p. 346) To say that mental illness is a social fact means that people accept that it is true and organize their lives around this belief. It is more of a phenomena of social groups than a reality of the content of that social group's belief.
Ryle’s Mind: Category Mistake
Szasz followed Gilbert Ryle’s understanding of myths being used inappropriately in a category when they are best suited in another. Ryle used this understanding of myth in his philosophizing of the mind and the category mistake people make. (Spillane 2018, p. 346) It is incorrect, according to Ryle, to try and locate the mind somewhere, in the brain. Szasz follows a similar form in logic to Ryle in the sense that analytically, the pathological definition of disease would make mental illness a metaphorical illness. If it is an analytical truth that mental illness is a metaphor there is no need for empirical falsification. Szasz disagrees with Quine that there are no analytic truths and
“applied the analytic-synthetic distinction to statements about mental illness to identify necessarily true and contingently true propositions and separate them from nonsensical propositions (including value judgements) which are neither true nor false.” (Spillane 2018, p. 346)
Szasz believed that a logical impossibility means an impossibility in anything that follows which is empirical, scientific or technical. The oxymoron status of the concept ‘mental illness’ falsifies itself because it is contradictory. Ellis’ response was not to challenge Szasz on the logical status of mental illness but to revert to the social fact that it was applied as a label to people who displayed irrational behaviour. (Spillane 2018, p. 346) Ellis used rationality to base his attitude towards mental illness whereas Szasz approached it with a criticism of the mind. (Spillane 2018, p. 347)
Rational Psychotherapy
Ellis’ ‘rational psychotherapy’ was developed using rational analysis and wisdom from stoics like epictetus. He distinguished neurosis as irrational self-talk and psychosis, like schizophrenia and bipolar disorder, having a biological root. These two psychological phenomena are fundamentally different and could be both present in the same person. Ellis’ final therapeutic model was called ‘rational emotive behaviour therapy.’ (Spillane 2018, p. 347)
Ellis’ rationalism was not that of the early moderns like Descartes but was based in the reasonability of one’s belief. Ellis thought that
“Beliefs are irrational [...] when they are self-defeating and dogmatic; beliefs are rational when they are self-promoting and entertained critically, which means that a critical stance should be adopted for all beliefs.” (Spillane 2018, p. 348)
He evaluated beliefs being rational using four criteria. First, if they promoted happiness and helped solve practical problems, it would be irrational if it was self-defeating and hindered problem solving. Second, a rational belief led to appropriate feelings of being concerned, disappointed, or irritated in contrast to inappropriate feelings of anxiety, depression and hostility. Thirdly, rational beliefs were supported by valid, logical reasoning and empirical evidence. Finally, critical thinking was used to dissolve dogmatic beliefs that were self-defeating like absolute concepts of ‘should,’ ‘must,’ and ‘catastrophic’ that lead to mental illness. (Spillane 2018, p. 348)
Ellis wanted to distinguish himself from psychological authoritarianism or intellectual/ rational fascism. His goal was to give up irrational beliefs rather than ascribe to the truth of rational ones, making his theory more in line with the critical rationalism of Popper than of the logical positivists. His pursuit with clients was to dispel their attachment to dogmatic beliefs using logic and argumentation to help them solve psychological problems rooted in problems of living. (Spillane 2018, p. 349)
Szasz’s Mind
Szasz’s theoretical framework begins from the philosopher/psychologist G. H. Mead’s social genesis of consciousness and self-reflexive thought. Mead’s view of the mind was a relationship between the linguistic community and an individual’s responsibility; not something we possess. In this view, language comprises nearly everything in human life. Szasz takes this understanding as the basis for the mind being mediated through language, enabling self-conversation and identifies the mind as inner dialogue. (Spillane 2018, p. 350)
Szasz discusses the etymology of the term mind, noting that before the 16th century people talked about souls and used mind in the context of attending to, or minding something. Mind is from the Latin term, mens, meaning intention or will. The term mind is not a thing but an activity as it is was used as a verb. Szasz reasons that the mind cannot be the brain because it is not an entity. There is a difference between the concrete noun of brain and the abstract noun of mind. Abstract nouns are not terms that refer to entities we can observe. (Spillane 2018, p. 350) Spillane states,
“In psychology and psychiatry, considerable confusion has resulted from reifying such abstractions as mind, consciousness, personality, ego and self…Minding means attending and adjusting to one’s surroundings, by talking with others and with oneself. To be able to mind, one has to be able to think—to talk to oneself.” (Spillane 2018, p. 350)
Philosophically, thinking is known as a mode of discourse where one makes statements to oneself. Szasz believes that the mind is our capacity to have conversations with ourselves. (Spillane 2018, p. 350) The mind or mental can also mean our capacity for attention, adaptation, perceiving, intending and states of consciousness as being awake or aware of our environment. (Spillane 2018, p. 351)
Szasz sees mindedness as having both consciousness and responsibility. Responsibility is the form of self-conversation when a person is determining the good or badness of their conduct. Mental discourse is one that assumes responsibility and human conduct is rule-following that entails purpose and meaning. He sees interpersonal relationships as games where the player’s behaviour is governed by explicit and tacit rules. Szasz believes that even though a mentally ill person’s behaviour may be bizarre, there is some ‘reason’ behind it. (Spillane 2018, p. 351)
Szasz’s Autonomous Psychotherapy
Szasz’s autonomous psychotherapy is based on players being able to participate when they are mature and have learned the social construction or deconstruction of the game. Within this, games can be played either honestly or dishonestly. An honest approach towards games means one acknowledges that players have the freedom to make moves as they want to and can be unpredictable. To play games one must tolerate uncertainty without being overwhelmed with anxiety. A dishonest approach, according to Szasz, would be where a person cannot tolerate uncertainty and seek to control and predict the behaviour of others with a temptation to lie or cheat. When playing honestly, the focus is on mastering tasks through knowledge and skill, whereas the dishonest approach, the focus is coercion and manipulation of others personalities. (Spillane 2018, p. 351-2)
Szasz took an interpersonal approach to people’s psychological problems and wasn’t interested in people's self-talk or what they say to themselves. He looked at the kinds of games people played socially, for example playing the role of and acting anxious. Existentially, Szasz believed that even though, in the social world, we may play different roles, if we are conscious, we ultimately always have a choice on which role we play. In contrast, Ellis’ view was that of an intrapersonal, cognitive perspective, focused on criticizing the irrational, dogmatic thoughts that cause personal distress.
Ellis vs Szasz
Ellis criticized Szasz for focusing too much on the lack of objective criteria of the definition of disease and pathology and it is better to focus on a description of misbehaviour as mental illness. (Spillane 2018, p. 354) Szasz viewed the DSM as a catalog of misbehaviours that are mistakenly called mental disorders. (Spillane 2018, p. 355) Even if the DSM was accepted as a catalog of misbehaviours, a misbehaviour is not an illness.
Szasz gives examples of misbehaviours that were once considered mental illnesses due to the political nature of them at the time: drapetomania, where slaves would run away from their masters, masturbation, and homosexuality. (Spillane 2018, p. 356) Spillane summarizes Szasz’s point stating,
“We should therefore not accept that the dynamics of the mentally ill person are different in kind from those of the normal person; they are merely inadequate for the adaptations demanded by the life situation.” (Spillane 2018, p. 356)
Szasz fundamentally sees mental illness as a form of medicalizing moral behaviour, where what is deemed as ‘immoral’ by society is categorized as an illness which holds consequences for the removal of the individual’s liberty. (Spillane 2018, p. 358)
Szasz believes that the morality of mental health is about developing courage, accepting tragedy when it occurs, creating autonomy in ourselves and helping others do the same. Spillane summarizes Szasz’s view stating,
“No one automatically develops mental health: as a moral condition it depends on choice and personal responsibility. If mental health is the result of people’s choices, they are responsible for maintaining it. Mental health depends on the brain only to the extent that all behavior requires a healthy brain.” (Spillane 2018, p. 359)
Ellis believed that mental health is a condition that one has, whereas Szasz saw mental health as something that one can achieve. Under Ellis’ view, mental health as a condition means that mental illness relieves someone of responsibility. For Szasz, having a personal choice for mental illness means someone can choose to not be autonomously responsible. (Spillane 2018, p. 359)
Synthesis
Both Szasz’ autonomous psychotherapy and Ellis’ rational emotive therapy can be combined to address the larger conceptual issues of problems of living. Szasz's social game model, where people are learning how to play rules within a social context as a means of dealing with problems of living and Ellis’ refusal for dogmatic thinking via reason to criticize unhealthy thoughts are not mutually exclusive. Both of these approaches can be combined in the ‘problems of living’ paradigm to mental health and in the implementation of the therapeutic community generalized model to society as a whole. The ethical discussion will assume that both of these approaches are being implemented in the therapeutic community model generalized to society to solve the problem of mental illness.
Part III: Therapeutic Community Case Study
Therapeutic Communities for Substance Use Disorder
De Leon and Unterrainer (2020) wrote an article about the development of therapeutic communities (TC) in the treatment of substance use disorders. The TC model is to break the attachment the individual has to the substance and shift attachment towards the community. The TC acts as a safe haven for the individual where they can work on having a drug free life. The TC offers a function for affection or emotional regulation with neuro- evolutionary support from the social baseline model stating,
“that social species are hard-wired to assume relatively close proximity to conspecifics, because they have adopted social proximity and interaction as a strategy for reducing energy expenditure relative to energy consumption.” (De Leon and Unterrainer 2020, pp. 2)
Depending on the pattern of drug use, people will vary in degrees of psychological dysfunction and social deficit. The TC offers a rehabilitation environment where the person can develop social ,productive and conventional lifestyle skills. Many individuals within the TC display antisocial and immature traits that correlate with substance use dependency. Psychologically, the main goal is to help negative thinking patterns, behaviour and predispose a person to substance use. Socially, the goal is a focus on skill, attitude and value development that promotes responsibility and living drug free. (De Leon and Unterrainer 2020, pp. 3)
For the TC as a method to work effectively, the person with substance use disorder may need either positive and negative motivational pressure. The individual’s attention and commitment to their own recovery/ change process is essential in self-help. In a communal self-help process, personal growth, right living, and recovery are supported through peer disclosing and sharing experiences in a group setting, and acting as role models who also encourage and support each other as friends in their daily interactions. (De Leon and Unterrainer 2020, pp. 3)
These lifestyle changes fundamentally occur within a social context and due to negative behavioural attitudes, behaviours and roles being acquired socially, they are expected to be overcome socially. De Leon and Unterrainer (2020) state,
“Social responsibility as a role is learned by acting the role within a community of one’s peers.” (pp. 3)
The TC promotes specific values, concepts and social perspectives that help people in the recovery process. In contrast, the TC will place sanctions on members who exhibit antisocial attitudes or behaviour.
“Positive values, by contrast, are given a positive emphasis as being essential to both social learning and personal growth. These values include such concepts as truth and honesty (both in word and deed), a strong work ethic, a feeling of responsibility for others (e.g. being one’s brother’s or sister’s keeper), a sense of achievement and that all rewards have been earned, self-reliance, personal accountability, community involvement, and social manners.” (De Leon and Unterrainer 2020, pp. 3)
The TC provides a context for right living that eschews negative values and habits and socializes its members towards positive values and habits. The TC gives people demonstrable examples of ways of living and dealing with intra and interpersonal problems.
The TC is a means for people to actively teach themselves using the community as a medium for change. The assumption within the TC is
“individuals obtain maximum educational and therapeutic impact when they engage in, and learn to use, all of the diverse elements of the community as tools for self-change.” (De Leon and Unterrainer 2020, pp. 4)
The phrase used to summarize this principle is the ‘community as a method’ underlies the capacity for individual change and learning socially. Every member has expectations and standards to live up to within the context of the community. (De Leon and Unterrainer 2020, pp. 4)
Living up to the ideal of the community means that every member will have to modify their behaviours, attitudes and emotions to the standards of the group. When difficulties occur, people can also experience growth via self-examination, re-motivation through trial and error and re-committing to the value of growth through change. Cohering to the community expectations through participating motivates people to achieve personal goals in their psychological growth and socialization,
“If you participate, then you will change.” (De Leon and Unterrainer 2020, pp. 4)
Replicability across many studies has shown a consistent correlation between treatment within the TC and positive results for members after treatment. Some of these studies include single program controlled studies, cost benefit ones, meta-analysis’ and effectiveness within multi-programs all showing that TC are effective in their cost and more importantly, in their effectiveness as a therapeutic treatment for substance use. (De Leon and Unterrainer 2020, pp. 4)
Democratic Therapeutic Communities for Personality Disorders
Pearce et. al. (2017) did a study on the effectiveness of democratic therapeutic communities (DTC) for personality disorders using a randomized controlled methodology. The DTC uses a psychosocial form of treatment that focuses on a collaborative and deinstitutionalized method towards interactions between staff and patients. Values of empowerment, personal responsibility, shared decision making and participation within the community are supported as the medium of socialization. (Pearce et. al., 2017, pp. 149)
Six fundamental principles distinguished DTC as a form of therapy. They were:
1) Democratization: decisions were shared for group issues in a transparent voting way to promote responsible agency.
2) Permissiveness: a variety of behaviours are tolerated as long as they do not harm others or negatively affect their treatment. The values of understanding and discussion are applied to behaviours instead of condemnation and forbidding them in a responsibility without blame perspective.
3) Confronting Reality: Patients and staff challenge behaviours and attitudes to get feedback about the impact a person has on others, in a compassionate and non-judgmental way.
4) Community: Shared living means staff and patients eat, do tasks, and enjoy leisure activities together. Everyone acts authentically and uses the process of living learning experience to deal with issues arising in daily life.
5) Enquiry Culture: the attitude of everything can be considered for questioning is upheld
6) Therapeutic Community Milieu: the community, including administrative processes, are all within the therapeutic context. (Pearce et. al., 2017, pp. 150)
It was found that the DTC was more effective than treatment as usual in reducing patients from self-harm, violence/ aggression and increasing satisfaction with care at a 2 year follow up with the control group. The DTC accomplished this via a context of challenge and support, the promotion of belongingness increasing well-being and mental health, responsible agency decreasing impulsivity and increasing self-efficacy and one’s capacity to make good decisions. (Pearce et. al., 2017, pp. 154-5)
Communities Treatment for Schizophrenia and Psychosis
Armijo et. al., (2013) did a meta-analysis on the effectiveness of therapeutic communities in treating people who suffer from psychosis. After analyzing 14 years of community based treatment, they found that it was an enhancement to treat schizophrenia in terms of recovery and social integration. Psychosocial interventions help in reducing positive and negative symptoms and psychopathology in general in the first occurrence of a psychotic episode and other stages of the illness. In a community format, there was also a reduction in relapse and hospitalization, increasing contact with mental health teams and medication use. (Armijo et. al., 2013, pp. 7)
The community based, psychosocial programs assessed helped with global functioning, one’s day to day living responsibilities, social functioning, and patient satisfaction. Job reintegration was produced through vocational interventions and psychoeducation helped understanding the nature of psychosis and managing crises as they happen. (Armijo et. al., 2013, pp. 7) The main successful therapeutic outcome of community based interventions is to give the person affected by schizophrenia and the family
“the ability to live independently, establish and pursue occupational goals, establish social relationships, and improve quality of life.” (Armijo et. al., 2013, pp. 8)
Case Study Summary
As we have seen from each different kind of mental health issue, substance abuse, personality disorders, and schizophrenia, the therapeutic communities do better than control alternatives in treating and increasing the wellbeing of the patients involved. Empirically this methodology has shown that it is appropriate to help people with nearly every major mental health issue as a problem of living.
We can inductively conclude that because of the success in these case studies, if society as a whole learned the practices and values of the therapeutic community model, we could essentially change the occurrence and prevalence of mental illness for every human being. If every person in the world were socialized to learn practices like those in the case studies above, we would be able to proactively prevent mental health issues from occurring and treat existing issues. This would reduce the pressure from mental health professionals who do not have the time to treat all the people that need their help. It would also give people who do not have the money to pay for a psychologist some form of intervention to guide them out of their problems of living to a lifestyle conducive with wellbeing.
Part IV: Ethical Analysis
After going through the definition of mental illness, how to approach it from a therapeutic process and a practical application via case study of Therapeutic Communities, now I will conduct an ethical evaluation of the ideas that were covered. I will discuss the ethical principles of autonomy, non-maleficence, beneficence, utilitarianism, universalizability, and Justice in the context of mental illness. The basic argument is that it is ethical for all members of society to embody the practices of the therapeutic community case study to increase the wellbeing of every member of society by proactively preventing mental illness and retroactively treating existing mental health issues. This argument is justified with the six ethical principles listed above.
Autonomy
Beauchamp and Childress (2009) defines autonomy as
“self-rule that is free from both controlling interference by others and from certain limitations such as an inadequate understanding that prevents meaningful choice…act[ing] freely in accordance with a self-chosen plan.” (99)
In Part I:Professional Intervention, Szasz discusses how the psychiatrist, as an agent of the patient, has an ethical obligation to respect the autonomy of the patient. In contrast, if the psychiatrist is an agent of a social institution like the legal system, the autonomy of the patient is disregarded even if the psychiatrist disagrees with the nature of the laws the patient may have violated. Who the psychiatrist is acting on behalf of, the patient or society, determines how they respect the autonomy of the patient.
In the same section, Szasz discusses how medical intervention is inappropriate, using tranquilizers and drugs, if mental illness as a phenomenon is not a physiological phenomena. If mental illness is a problem of living, then as we have seen in the therapeutic community case study, reinforcement and socialization to group norms can be used as a means to regulate problems of living without use of the physiological intervention of drugs. The Therapeutic Community case study shows how mental illness as problems of living can be addressed in a way that embraces the autonomy of the person who suffers from ‘mental illnesses.’
In Part II: Szasz vs Ellis, Szasz brings up how medicalizing moral behaviour has consequences for people’s liberty. If one is deemed mentally ill, they can be hospitalized against their will, hence taking away their autonomy. This can be justified in some sense if that person is a danger to themselves and others. The therapeutic community case study identifies how the socialization process is used to regulate negative behaviour and the value for belonging to the community motivates the person to act in prosocial ways. If the therapeutic community model was generalized to society as a whole, it may be possible to have interventions in a person’s life, over time, where they did not get to the point of being a danger to themselves or others. Ultimately, if the person lacks competency and hence a reduction of autonomy, they may not be making meaningful choices based on self-rule which could justify involuntary commitment to an institution.
Non-Maleficence
Beauchamp and Childress (2009) define non-maleficence in reference to the hippocratic oath,
“I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.” (p. 149)
Initially, we can discuss the legitimacy of Szasz’s criticism of mental illness as a problem of living and not a physical illness. If we conceptualize incorrectly what the phenomena we refer to when we say mental illness, our treatment will be misguided like an exorcism banishing the demons from a possessed person. Even if the treatment in question does not direct harm, it can pose an opportunity cost to the patient in the form of missing out on alternative treatments that demonstrate efficacy in helping the person with the issue they are having.
It is fundamentally important that the paradigm used to understand mental health and illness is accurate in how it is operationalized via the words corresponding to observable phenomena and that the treatment produces the effect of increasing the patient’s well being relative to the problem they are facing. If the patient is wasting time on treatments that are related to a misconception of mental health when other, more efficacious treatments are available, it can be said to be causing harm, and hence unethical. To ensure we are not causing harm in our treatment of mental illness, conceptualizing the nature of mental illness as problems of living is primary.
Beneficence
Beauchamp and Childress (2009) define beneficence as
“all forms of action intended to benefit other persons.” (197)
From the case study provided on Therapeutic Communities, if society in general learned how to respond to problems of living with each other, we would all be engaging in a benevolent moral duty to others by responding to issues as they arise. It is much more efficient and effective if society as a whole took responsibility for each other by learning how to respond to problems of living as those problems arise. Through some form of educational context, as seen in the therapeutic community case study, it would be in the interest of all members of society, hence their benefit, if we had some education and training on how to most effectively deal with problems in our relationships with ourselves and others.
The therapeutic context could be limited to extreme cases, whereas the general population’s response to each other through informed and accurate skill based training, could reduce the overall mental health problems we face today. There are many forms of action that would benefit each other and the educational system or independent social organizations could facilitate this as seen in the positive results from the therapeutic communities.
Utilitarianism
Beauchamp and Childress (2009) define utilitarianism as
“seek[ing] to maximize social welfare,” (245) or a decision is ethical when it creates the greatest happiness for the greatest number of people.
In terms of implementing a social framework based on the therapeutic community case study and the problem of living discussion between Szasz and Ellis, it would be ethical if everyone learned how to respond to issues to proactively prevent mental illness from occurring. If people respond to problems of living in the moment, then the issue would not persist and always have some form of reinforcement that is directly related to the best practices treatment for that issue in question. This would be a utilitarian ethical decision because everyone in society learning how to respond to problems of mental health would then in turn produce the greatest happiness for the greatest number of people in society. We would effectively be changing the landscape of mental illness and mental health by not delegating all of our mental health issues to the professional community.
If society was educated and trained on how to respond to themselves and each other, then we would all be better off and our collective wellbeing would increase. Ignorance and avoidance of accepting and dealing with our own and other’s mental health issues actually makes matters worse and exponentially causes more problems. Not only is it ethical from a utilitarian perspective, it simply makes sense to be proactive in this regard. This model would also retroactively help people with existing mental health issues because the way those in their lives relate to them, reinforces ways of living that are conducive to wellbeing and being mentally healthy.
Universalizability
Velasquez (2006) defines the Kantian principle of universalizability as
“principles must apply equally to everyone.” (97)
The principle found within the therapeutic communities and argued to be generalized to society as a whole is a universalizable principle, assuming that the person has sufficient cognitive capacity. Every person with agency in society can learn how to respond to themselves and others in a way that increases everyone’s mental health.
If someone lacks autonomy due to some cognitive limitation, we simply become the caretakers for them. This is how our society already functions with those who lack cognitive capacity, like in the case of autistic people living in group homes, alzheimer’s patients being taken care of family or people with down syndrome having a personal support worker traveling with them in public transit.
Justice
Beauchamp and Childress (2009) define
“justice as fair, equitable, and appropriate treatment in light of what is due or owed to persons.” (241)
Assuming we accept the value for wellbeing as a human right, it is only fair that society and each member takes responsibility to learn about practices that can help increase the wellbeing of ourselves and each other. We all are owed and are due wellbeing and we can achieve that as a society if we put the effort in to learn and adopt values and traditions that embody ways of living that are correlated with wellbeing. This is seen in the case study of Therapeutic Communities.
Conclusion
As we have seen in our philosophical analysis of mental illness, approaches to treating problems of living, case studies in applications of problems of living and an ethical analysis of what society ought to do, there is a way for humanity to leave mental illness as we know it as a historical anecdote. If we are able to socialize with each other with the value of approaching ourselves and others in ways that are conducive to wellbeing, we can overcome the current paradigm of mental illness and live in a better world.
It is not necessary for so many people to suffer and continue suffering if we simply begin to learn new skills and ways of relating. If we take seriously the nature of the mind and how it can deviate from a harmonious state to states of extreme suffering, we can begin to recognize that some effort pays off in the long term for ourselves and everyone else. How we treat ourselves and each other is the pinnacle of what it means to be mentally healthy.
We do not have instincts that teach us these skills automatically. We must learn them either from our early care givers or from some social institution that we have created that explicitly teaches people how to deal with problems of living. Our evolutionary history has given us the capacity to learn but it is up to us to determine which content we will fill our minds with.
We know that mental health has and is a problem for humanity. So when will we decide to take responsibility for ourselves and each other, and make mental illness a thing of the past?
References
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