When Szasz argued that mental illness is a myth, I do not believe that he was suggesting that societies could do without myths. It was to claim that the word ‘illness’, in the phrase ‘mental illness’, was a metaphor. The aim of this chapter is to discuss how a belief that another person (or oneself) is mentally ill is related to a belief in ‘free will’, a belief that seems to incorporate an element of mythology. An ability to exercise choice is fundamental to the definition of all woes. A woe denotes a state of affairs in which a person typically acts, thinks, or feels in ways that are upsetting to self or others. Attempts to redress this state of affairs often turn out to be self-defeating, and the person becomes resigned to bearing a burden of distress. Mental illness is put forward as one explanation for this kind of departure from a state of mind or behaviour that is classed as freely chosen and accords with whatever is considered reasonable or acceptable. In past eras, a person might have believed that their will had been taken over by a superior power, such as a god or demon.
As an assumed ability, ‘free will’ is mythical in the sense that being in possession of a ‘will’ that freely chooses is not something that can, at present, be translated into terms that would satisfy a natural scientist. At best, we can trace the development during childhood of a capacity to choose freely and assess this against social criteria marking its accomplishment. Although the way in which ‘free will’ is acquired may not be transparent, a belief in it (as some kind of human faculty) is something that most people take for granted. In this chapter, I will assume that a belief in ‘free will’ performs a socially necessary function, and follow Ryle (1949) in asserting that will or volition is an after-the-fact description for a certain class of behaviour that has to be learned in childhood. In other words, it is not an ability with which humans are naturally endowed but a product of how we are socialised. Of course, humans, like all animals, have certain ‘natural’ agentive powers. At its most basic level, individuals engage in voluntary behaviour when they acquire the capacity to indicate a request, accede to a request, or refuse it. This kind of behaviour is observable in primates and pre-verbal infants. In the failures of agency that are now explained as mental illness, a person cannot easily implement what they want to do or stop doing what they (or others), do not want (them) to do.
After elaborating the role of agency in so-called mental illness, I discuss the special case in which coercion is employed in an attempt to change the way a person behaves in order to protect others or the person him or herself. Coercion, if used at all, is usually confined to what could be termed the ‘hard cases’ of so-called mental illness, although the great majority of people labelled mentally disordered are, in reality, ‘soft cases’ – that is, people who recognise the need to make a change but have difficulty in doing so. I discuss how these two groups of people have been labelled, the kinds of explanation that are produced for failures ‘to adjust’, and criticise attempts to normalise mental illness as just another kind of illness that anyone might happen to suffer from.
Most people, most of the time, do acquire the ability to adjust their behaviour to bring it in line with their own wishes or to take account of the distress or annoyance it might cause others. If they are unable to do so, the inability may appear, even to them, as surprising and inexplicable. This kind of situation is nothing out of the ordinary. It develops into a state of so-called mental ill-health only when a person fails to find a way of successfully resolving it. A person might then be viewed as lacking resilience or self-determination, or as having a character weakness, such as being oversensitive or easily overwhelmed. In making these social judgements, other people are often ignorant about the impact that a woe is capable of having or what it is that makes a person particularly susceptible to it.
People are often reluctant to attribute their failure to act ‘reasonably’ to causes outside of their own control. They hold a conviction that their power of volition or their ‘free will’ should suffice to ensure that they are able to govern themselves rationally, morally, or wisely. Right living – that which promotes the good life and lessens the chance of experiencing woes – is thought to depend on freely exercised ‘right choices’. People are held (or hold themselves) accountable when they fail to live up to their own or others’ expectations. The State assumes this to be the case and so its methods include incentives for behaving well and disincentives for behaving badly. The Law may be employed to bolster our personal powers, which are prone to slippage. For instance, it requires a law and penalties to ensure use of a seat belt when driving a car. The ability to choose reasonably is not, therefore, simply an internal power because it has to be propped up by a system of social consequences. In the presence of sanctions, we ‘freely choose’ to attach a seat belt and feel that this is a matter of our own volition, having accepted the rationale for belting up. However, when we disagree with the rationale for a sanction, the latter may be experienced as coercive.
The so-called mentally ill form an extremely heterogeneous class of persons, but two sub-groups are typically differentiated: the ‘severely mentally ill’ and people with ‘common mental disorders’. Although there is no clear dividing line, the former are likely to be seen as showing a greater lack of the tools for acting reasonably and with insight. They may, for instance, have experiences of an alien and imposed nature that take the form of altered states of consciousness. The person concerned may have little or no sense that they have played a part in willing them. Consequently, an illness explanation comes naturally. By contrast, so-called ‘common mental disorders’ are more likely to be attributed to ‘psychological’ (willed and modifiable) causes rather than the imposition of illness. The onus for resolving them is more firmly placed on the individual. A person is aware that something that they believe, do, or feel is irrational or out of their control despite their endeavours and self-admonishments. They have no difficulty in taking another’s point of view and can usually see the desirability of changing (or concealing) some aspect of their behaviour. In essence, they fully acknowledge ownership and would agree with Szasz that even if they were to receive a diagnosis of mental illness, they would be morally accountable for resolving their problem. However, despite feeling personally responsible, a solution to their problem eludes them. Attempts to change may have made matters worse. The phrase ‘neurotic conflict’ refers to the self-defeating quality of worthy but failed attempts to change a woeful state of affairs. If the failure relates to an important area of life, their loss of control may induce a sense of shame or guilt.
The norms for judging a person’s acts and their capacity to deal with a woe clearly vary greatly across cultures, historical periods, situations, and a person’s age, status, and other characteristics. Shared norms are by definition internalised, and consequently, people may censure themselves, judging that they are ‘abnormal’ or ‘failing to cope’ (Thoits, 1985). One purpose of a psychiatric manual of disorders is to set out thresholds for what is considered to be the norm against which a person can be judged to have a mental health problem. When a norm is not shared, a person may reject the idea that their deviation warrants censure. For instance, there is a minority opinion that society is ‘insane’ and that ‘madness’ is a gift (Farber, 2012).
In the uncompromising language of sociology, mental illness is a form of deviancy attributable to mental or behavioural disorder. People are labelled as deviant when their behaviour affects or offends others and is unresponsive to attempts to induce conformity. Family, friends, or employers may perceive a need for ‘treatment’ or even hospitalisation. This form of labelling is, of course, made easier by the existence of an official set of disorders into which a person’s behaviour can be fitted.
The other major class of deviancy is reserved for people who commit criminal offences. The two groups overlap. A high proportion of prisoners have either received treatment for a ‘mental health problem’ in the year prior to their sentence or they meet diagnostic criteria for mental illness while in prison (Prison Reform Trust, 2017). Cohen (1985) refers to ‘hard’ and ‘soft’ deviants, the former requiring firm (occasionally involuntary) social interventions. Soft deviants are those who are responsive to social sanctions; they may recognise the need to change and want help, or they are thought likely to respond to rehabilitation or therapy.
The State is primarily concerned with the ‘hard cases’ of so-called severe and persistent mental illness. The Mental Health Act 1983, amended 2007 (UK Government, 2007), defines a mental disorder as ‘any disorder or disability of mind’. In principle, this tautology allows mental disorder to be whatever the State wants it to be. In practice, lawyers rely on psychiatric expertise, and the power of psychiatry resides in the performance of this role. Unlawful deviance due to so-called mental illness is differentiated from ordinary crime on the grounds that, with the latter, it must be established that there was intent for the criminal act to be committed, and that the act was voluntarily wrongful. A lawyer might argue that ‘intent’ cannot be demonstrated by reason of mental disorder, and that a person is therefore unfit to stand trial. Furthermore, when a person’s ability to think rationally and act accordingly is called into question, it may be assumed (rightly or wrongly) that there is a risk that the person will cause harm to others in future. This reasoning can then be employed to justify a diagnosis of mental illness and compulsory hospital or community treatment. Thus, the law is not reserved only for people who have already acted in a threatening way and pose an obvious risk.
The Mental Capacity Act (2005) applies to people whose ability to think and act reasonably is questionable. It sets out principles for judging a person’s capacity to understand and make a decision based on relevant information. Although its application is not contentious in many circumstances, this may not be the case with so-called mental illness. The Mental Health Act can, in fact, trump the Mental Capacity Act (Spandler and Anderson, 2015: 17). For instance, a person may have mental capacity in the sense of appreciating the pros and cons of taking psychoactive medication and be capable of making a decision about it. Nonetheless, this form of treatment can be imposed involuntarily. The 2007 amendment to the Mental Health Act introduced Community Treatment Orders, which are a form of conditional release from psychiatric inpatient care. The eligible patient must continue to take medication and agree to be monitored by a mental health professional. Their refusal to do so raises all of the expected dilemmas surrounding the use of a concept of mental illness to justify social control – that is, whether the policy is intended to be therapeutic for the person concerned or whether it is designed instead to reduce the perception of risk to the public. It can be difficult for a professional to remain helpful in a constructive (and non-coercive) manner when a person’s right to freely make a decision about treatment can be ignored (Morgan and Felton, 2013).
Despite the humanistic foundations of Western society, it seems quite capable of inspiring subtle forms of coercion. Friedli and Stearn (2015) make out a case that welfare policies have constructed a psychological ideal that links unemployment to psychological deficit. The coercive element comes in by linking eligibility for social security benefits with various activities that are intended to modify attitudes, beliefs, and personality. This may include engaging in mandatory unpaid labour for its ‘improving’ effect. The underlying assumption is that unemployment is the result of personal failure and psychological deficit. Although allegations of mental unfitness do not imply a diagnosis of mental illness, they certainly border on doing so.
One recent government policy initiative aroused vigorous criticism and street protests. This was a decision to locate a therapy service in job centres for the unemployed. A Government manifesto of 2015 had stated that claimants who ‘refuse a recommended treatment’ may have their benefits reduced (Callard and Stearn, 2015). A letter of protest from 442 psychotherapists, counsellors, and academics appeared in a national newspaper (The Guardian, 2015). The policy proposal led five national organisations representing the interests of psychologists, counsellors and psychotherapists to request meetings with Government officials to seek reassurances. Two of their main worries were about people being coerced into therapy (or face sanctions), and human rights concerns about privacy and confidentiality.
The key to success in most forms of individual psychotherapy is to clarify what a person’s problems are and what they can do to overcome them. The merest hint that this kind of therapy is covert coercion, with financial penalties for failing to engage in it, violates the ethical standards of all professional psychotherapy organisations. The prescription of a pharmaceutical drug is not always accompanied by a diligent search into the causes of a problem, but one can imagine the uproar if welfare claimants were required to take medication in order to receive their benefits.
Discussion of mental illness by social scientists is weighted towards the ‘hard cases’. In reality, the soft cases comprise the majority of people who are potentially ‘diagnosable’. However, the soft cases may not have been referred to secondary care where they could be officially diagnosed. The results of a UK survey (NHS, 2015) found that 6 per cent of men and 7 per cent of women reported taking psychoactive medication or engaging in therapy even though they did not claim to have experienced a mental health problem in the previous twelve months. It seems that even without a diagnostic label, a considerable number of people use medication or seek therapy. It is possible that some survey respondents were taking medication as a form of prophylaxis or they feared the return of ‘symptoms’ (or withdrawal effects) on stopping it. As regards antidepressants, there appears to be an accumulating proportion of people who, once started on them, decide to continue with medication indefinitely, and this can partially account for the rising number of annual prescriptions (Moore et al., 2009). Another indication that ‘soft cases’ of so-called mental illness predominate is the fact that work stress appears to be the main reason for people to visit a general practitioner (CIPD, 2011). Work stress may not result in a psychiatric diagnosis, but psychoactive medication is often prescribed in an attempt to manage it.
Seeking help for an assortment of woes, problems, or stressful situations is now commonplace and does not imply ‘deviancy’ in a strong sense. However, when a person formulates their problem as a disorder, it implies indoctrination into a concept of mental illness. The rising number of prescriptions for psychoactive drugs (HSCIC, 2015) suggests that medication for so-called ‘common mental disorders’ constitutes the backbone of present-day mental health services. Given a lack of alternatives, a medical route may be the only way a person can signal a difficulty and access a service. Taking a psychoactive drug might not be perceived as coercive, but it can be interpreted as a means by which deviance from social norms is managed.
Given that it is now so common for a person to seek help for a problem, it is not surprising that attempts are made to normalise ‘mental illness’ itself. In some cases, people formerly regarded as mentally ill have now come to be viewed simply as ‘different’. Their behaviour has been de-medicalised. Certain differences between people are treated as acceptable examples of human diversity. Even one of the cardinal signs of madness, ‘hearing voices in the head’, has been normalised on the grounds that it is a very common phenomenon in the general population. The experience chiefly becomes distressing because of the way it is interpreted (see Chapter 8). Another normalising strategy is to attribute problems to impairments or disabilities rather than to mental illness (see Chapter 6). This removes the grounds for self-condemnation because a person is not usually regarded as being responsible for any impairment or disability they might happen to have. Rather than resorting to these normalising strategies, de-stigmatisation campaigns put forward the case that mental illness is an illness ‘just like any other’. Consequently, it becomes an affliction, and not something that a person him or herself brings about through their own volition. The effect of this manoeuvre is to downplay the role of social processes that may have caused the woe while at the same time upholding the illness myth.
Critics of medicalisation sometimes choose a replacement term for mental illness that similarly de-emphasises its relationship to a process of social control. Beresford (2013a) refers to madness and distress, Pilgrim and McCranie (2013) to madness and misery, and Crombey, Harper and Reavey (2013) simply to psychological distress. These replacement terms represent an attempt to be non-judgmental and to convey the idea anyone can be distressed or act in a mad way. Deviance is ‘normalised’ by assimilating ‘mental illness’ into a common vocabulary of everyday words. This strategy risks creating euphemisms for mental illness or allows the new term to conceal the role of social appraisals of a person’s behaviour.
Research on the prevalence of ‘mental illness’, defined by self-reported ‘symptoms’ on questionnaires, gives the impression of a continuum of distress and underplays the labelling of certain people as disordered. Crombey and colleagues (2013) point out that there is no fixed line between the normal and abnormal. Although this is true, it remains centrally important how the line is drawn, on what basis, and according to what criteria and attributions of causality. If the concept of mental illness were to be abolished, the tendency to categorise people as socially deviant would be unlikely to disappear. A somewhat different set of criteria for ‘normality’ would be created, and various labels applied to people who did not meet them.
As already noted, de-stigmatisation campaigns attempt to remove the distinction between physical and mental illness, thereby removing any warrant for disapproval of the latter. Mental illness is assumed to be a natural phenomenon rather like malaria. Twinley implies that there are perspectives other than a medical one when she refers to ‘a social model of mental disorder’ (2014: 165). It is implied that mental disorder is a phenomenon about which social scientists could have different theories. However, if mental disorder is a myth, the function of social theory should be to explain the myth’s existence rather than to assume that ‘mental disorder’ is itself something to be explained.
A reluctance to dispense with medical terminology can be detected in other commentaries on social policy. Sapey, Spandler, and Anderson refer to the ‘medicalisation of mental illness’ (2015: 4), implying that mental illness is a universal category and that medicalisation is a local (cultural) variant. Weinstein argues that social workers need ‘to locate and own a model of mental health that acknowledges the importance of accurate diagnosis but is not over-reliant or dependent on medical models’ (2014: 12), a narrow path that seems rather difficult to tread, and does not represent an alternative to the medical model.
To advocate abolition of the concept of mental illness, and view it as a form of mystification, is not to belittle the problems of people who are distressed, impulsive, out-of-control, bothered, or woeful for all kinds of reasons. Some people might resent receiving an illness diagnosis, but mental health workers may be forced to adopt one because it is the only way they can make a case for support (Spandler, 2014: 33). Abolishing the concept of mental illness does not mean removing a need to evaluate, intervene on, and in some cases sanction, behaviour that creates a problem for self or others. Debates about the contravention of norms would simply revolve around different criteria such as a person’s agency, their human rights, the reasonableness of their desires, and their willingness and ability to change.
Szasz believed in free will and personal accountability for problems in living. Consequently, he thought of therapy as an exercise in rhetoric that addressed moral issues. For him, an explanation in terms of natural causes was irrelevant unless it concerned verifiable somatic disorders. This seems to leave no room for natural science to account for either free will or problems in living. The alternative I sketch out here argues that the myth of free will serves a useful function. In brief, I suggest that the myth supplies one workable arrangement for organising human relations, and that when it fails to do so successfully, the natural sciences have a useful part to play.
It is evident that people usually manage to demonstrate free will when provided with an intelligible motive for freely choosing something they want (i.e. when not under direct external compulsion). People choose freely most of the time when others expect them to do so and when their choices are consistent with an estimate of their own powers to enact that choice. It is also evident that people are occasionally unable to choose freely despite their efforts, in which case the failure may be attributed to ‘psychopathology’. In these instances, the foundational assumptions of the myth of free will are not supported. However, if a belief in the myth, and its efficacious functioning, depend on optimal conditions for its acquisition in childhood, occasional failures to act upon it can be expected. Any natural causal theory that is in a position to predict these failures is strengthened as a valid scientific explanation of their occurrence.
The philosopher Schlick (1939) offered an early deterministic theory of free will. He avoided metaphysical questions about the truth of determinism and focused instead on how people actually acquire the ability to be responsible for their own acts. His idea was simply that a child learns to be responsible through the judicious application of reward and punishment for choosing the moral and/or reasonable/expected action. In other words, it is a product of social influence, chiefly parenting and education. These external influences are subsequently internalised so that a person feels responsible and acts accordingly. At this point, any transgression induces a sense of self-reproach.
Schlick emphasised the judicious application of reward and punishment, although the process of judging others need not be conscious or deliberate. It is directed towards a person who is acting independently of influences that would otherwise compel a certain response. It is clear that an adult human being is being held to account, and one who is sufficiently socialised into the concept of responsibility (i.e. a child ‘who does not know better’ is not yet fully trained in this respect, and in this case, the social appraisal of conduct is tempered by the need to educate). Schlick emphasised that the social judgement is not concerned with taking account of causal influences such as a person’s genes or the character of their grandparents. However, in the immediate situation in which a person’s act is being evaluated, the application of praise or blame takes account of external factors that are not under a person’s direct control (e.g. inebriation or an emotion of fear induced by danger). Schlick makes the indisputable point that: ‘If decisions were causeless, there would be no sense in trying to influence men’ (1939: 157). In his opinion, the more motives we can find for an act, the more we regard a person as responsible for it. Schlick states that ‘In general we know very well how to discover the causes of conduct in the characters of our fellow men, and how to use this knowledge in the prediction of their future behaviour . . .’ (ibid.: 157). This sounds rather over-optimistic but for Schlick’s account to be credible, there must exist sufficient consistency (i.e. normativity) in social responding for a sense of responsibility and its limits to be acquired.
As regards the feeling of being responsible for one’s acts, Schlick argued that the subjective feeling coincides with the objective judgement. In other words, ‘the person blamed or condemned is conscious of the fact that he was “rightly” taken to account’ (ibid.: 151). In addition to a person being seen as the true doer of an act must also be added ‘the awareness that he did it “independently” on his own initiative’ (ibid.: 154). On Schlick’s account, the consciousness of freedom is a kind of felicitous delusion that is self-fulfilling because the freedom we ascribe to ourselves informs the evaluative judgements we apply to others – which guarantees their ‘freedom’ also because it is the means by which agency is acquired. The account is credible because it is consistent with what we know about the effects of inadequate parenting or abuse in early childhood that can lead to the loss of a normal sense of agency. It may lead, for example, to an adult being under-assertive, feeling overly responsible, or conversely, acting with a sense of entitlement (e.g. de Carvalho et al., 2015; Hengartner et al., 2015; Huh et al., 2015).
Schlick did not seem to appreciate the difficulty of applying his ideas to the behaviour of the non-average person who does not act as expected:
In the case of a person who is mentally ill, we do not consider him free with respect to those acts in which the disease expresses itself, because we view the illness as a disturbing factor which hinders the normal functioning of his natural tendencies.
Schlick, 1939: 151
This is a neat summing-up of the social function performed by the concept of mental illness. Schlick does not offer an independent definition of mental illness, and so his statement is an example of circular reasoning. It amounts to saying that whatever removes our normal volitional powers can be explained by mental illness (the evidence for which is the loss of our volitional powers).
Schlick’s employment of the concept of mental illness to explain why some people are stripped of their power of agency has been criticised by Pickard (2015). She points out that most workers in the field of mental health do not think of agency in this all-or-none fashion, and do not attribute a person’s failure to change to the presence or absence of mental illness. As Pickard puts it, the agency of clients/patients/service-users is only impaired relative to the norm. In her view, deviant behaviour should be classified as an act implying intent, and therefore a behaviour over which a person can exert some control. In the case of acts associated with so-called mental illness, we might desist from blaming a person (knowing it to be ineffective), but still hold a person responsible and capable of showing a willingness to change. For example, from the fact that an addict can control their compulsive habit under some circumstances, Pickard argues that he or she ‘possesses the general ability to control their use in a broad range of circumstances’ (ibid.: 148).
The assumption of a general ability (undefined) seems to overstate the case. Rather, control is possible under certain circumstances, justifying the belief that control could possibly be extended to new circumstances. This is a judgement that may or may not be borne out by experience. If it is not, or if some previously undetected and powerful causal influence is discovered, one might as well say that the person lacks agency (with regard to their particular problem) in any meaningful sense. Pickard suggests that the ‘general ability’ just mentioned could be construed metaphorically as a faculty of willpower, acting rather like a muscle (Muraven and Baumeister, 2000). Willpower, according to this account, is seen as an ability for conscious and sustained effort. However, if at some point willpower fails, what are we to conclude? We can agree with Pickard that a belief that a person’s behaviour is caused by an illness or disease is likely to have a disempowering effect because it would diminish motivation to exercise whatever willpower a person possesses.
Pickard’s argument blurs the meaning of voluntary to include ‘potentially voluntary’. Her analysis corresponds to Szasz’s adoption of the distinction between causes and reasons (which also translates for him into physical illness versus so-called mental illness). Pickard states that where executive function is lost due to a physical state, ‘behaviour approximates an automatic reflex’ (2015: 156). An alternative to this position, consistent with natural causation, is to abandon the assumption that ‘naturally caused’ means ‘illness’ (or, indeed, any other special category of ‘automatic process’ in the body). This implies that it is necessary to reinterpret the cause/reason dichotomy so that it can be reconciled with the natural causation of all behaviour.
As Schlick argues, the distinction between voluntary and involuntary rests ultimately upon a social evaluation in relation to particular circumstances. Although the categories of behaviour referred to as ‘naturally caused’ and ‘reasoned’ must have some different causal antecedents, these are not at all easy to identify. Even the eye-blink reflex has voluntary and learned elements and has been classified into different types (Rasmussen and Jirenhed, 2017). In fact, acts regarded as involuntary could have many complex causes, including the effects of the deliberate social appraisal of an act, whether delivered by others or oneself. If Schlick is correct that free will is acquired and maintained as a result of education and the social appraisal of conduct, there is no reason to discount the possibility that mal-education and ‘unreasonable’ social appraisals can result in conduct labelled as ‘mental illness’.
The judgement of an act as ‘voluntary’ depends in part on what is regarded as ‘normal’ (i.e. socially approved) in the circumstances. From the standpoint of natural causation, it is hardly credible to suppose that voluntary and involuntary acts have neatly segregated causes. In any case, the existence of voluntary behaviour would be implausible without involuntary processes to support it (Roessler, 2003; Hallam, 2009: 191–214). Moreover, an act that is done initially freely and for a good reason may become a strong habit and eventually develop into an involuntary compulsion.
Consider, as an illustration of social appraisal, the fact that mothers are not viewed as showing compulsive (involuntary) love for their babies, even though they would find it extremely difficult to alter their habitual behaviour. Rather, mothers who freely volunteer that they do not feel motherly (but continue to mother their babies) are often regarded as ‘pathological’, even though their non-motherly feelings are not experienced as compulsive. There may, of course, be certain responses that are always judged to be reflexive (and are therefore experienced as involuntary), but both simple and complexly determined behaviour share the capacity to be influenced in such a way as to be perceived as freely chosen or, contrariwise, imposed (determined).
Abolition of the concept of mental illness would only rule out certain kinds of assumption about natural causes, namely, the sorts of unsubstantiated criteria put forward to claim that a mental illness exists. In textbooks of medicine, psychiatric disorders, if they are mentioned at all, are included under neurology (e.g. Goldman and Schafer, 2015). It is assumed that ‘mental illness’ is caused by a neurological disease (which in certain cases it might be). However, ruling out neural pathology does not mean that so-called mental illness is not mediated by natural causes.
The standard interpretation given to the natural causation of ‘mental illnesses’ is that they have to be traced back to a stand-alone brain – that neuroscience will provide the key to future progress. This belief does not do justice to natural causation at a societal level of analysis. For example, emergent processes in human behaviour (emergent at the individual or collective level) can be assumed to be examples of natural causation (Elder-Vass, 2010). Brain-based theories of the causes of so-called mental illness seem to have been led astray by religious and philosophical beliefs about human nature (Hallam, 2012). This leads to a search for the origins of ‘willpower’ in the brain because this organ is understood to be the seat of the mind (originally the soul with all its God-given faculties).
On Schlick’s account, a person’s ability to distinguish between what are normatively classified as voluntary and involuntary acts is necessary in order to judge them and assign moral responsibility. Mental health professionals in non-coercive settings work on the assumption that a person intends to change, and all parties presume that change is possible. However, a person’s intention to exercise responsibility does not guarantee that change will occur. In any case, psychosocial formulations of problems frequently distribute responsibility to other people as well, for instance, to a past or present abuser, who could be a parent (Pilgrim, 2016). Therefore, in theorising a person’s responsibility for making a change (from a natural science perspective), the analysis can extend far beyond the identified client/service-user. In fact, a person might be invited to consider the causal influence of others (or cultural assumptions that they endorse) in order to gain a better appreciation of their ownership of a problem. This may result in re-assigning responsibility to other people. The purpose is not to remove personal responsibility but to relieve a person of unreasonable blame or guilt in line with common assumptions about what it is ‘reasonable’ for any person to be responsible for.
The role of volition in therapy is therefore complex. Clients/service-users frequently choose to be influenced by interventions over which they have no direct control. This clearly applies to any medication that affects the brain. However, in re-skilling and other re-learning methods, a person also submits to a method whose outcome they cannot predict with certainty. For this reason, there are ethical controls on false representation of the benefits to be had from applying any therapy technique.
When a person acknowledges the existence of a problem, there is a rather subtle relationship between the self that wills to change and that part of the self that is externalised as ‘the problem’. This has been well described by Rego (2004), drawing upon the writings of the philosopher Harry Frankfurt (1988). A person who is so enmeshed with their problem that they cannot perceive what it is must first externalise it in some way in order to be able to address it. Typically, this leads to discord between their frustration or unhappiness and their uncertain ability to do anything about it. By dissociating that part of themselves which constitutes the problem from the self that chooses to overcome it, a person is able to reflect and employ their agency from a new standpoint. The essential idea drawn from Frankfurt is that there are first order, second order, and third order thoughts or desires. For example, a person might want to smoke, want not to smoke, and also think that it is idle to contemplate whether or not to give up smoking (third order), given the strength of their addiction. A person at some point decides which attitude to adopt and withdraws allegiance from the other options. This effectively ends the appeal to higher order thoughts or desires even though they may remain available for reflection. According to Frankfurt, a person’s decision to adopt an attitude to a problem contributes to the way they define their identity. As Rego summarises his position: ‘The patient can now treat him- or herself in a manner of speaking. She or he can relate to the problem at hand in a quasi-third person style by appreciating its characteristics and interacting with them in a prescribed manner’ (2004: 316).
The medical model of woes is also a form of objective distancing. A bodily symptom can be viewed from a second order perspective, assuming that the illness is not an advanced dementia that precludes reflection and memory. The chief problem with the view that mental illness defines what a person is (e.g. unstable, neurotic, depressed, deluded, etc.) is that it discourages the employment of higher order perspectives. The biomedical model assumes that what a person has to deal with has already been decided. In this way, it reduces the options open to them.
It is well documented that people go through various stages when they entertain making a change and then act upon it. Prochaska, DiClemente, and Norcross (1992) describe the stages as pre-contemplation, contemplation, action, and maintenance. This sounds like a well-thought out reflective process, but the experiences that prompt reflection have a complex relationship with a sense of agency and self. A person’s unwanted experience may already be ‘external’ if it lacks a normal sense of ownership, and consequently it may be perceived as an intrusion that is attributed to alien forces. The problem is still one’s own (‘this is happening to me’) but a sense of agency is lost, i.e. some alien process or person is causing it to happen (Gallagher, 2004). There are also lesser degrees of a loss of agency, e.g. ‘I feel compelled to think certain thoughts’, or ‘I can’t stop myself having this impulse (even though I know I won’t act upon it)’. All of this suggests that a sense of agency is, at times, a fragile construction. From a medical perspective, unwanted experiences interpreted as symptoms have been attributed to neural dysfunctions, but this still leaves a person in the position of trying to make sense of them. The attempt may produce bizarre results, but as Gallagher notes in relation to a diagnosis of schizophrenia: ‘Some level of the schizophrenic person’s thought must remain unaffected by the disruption of agency, otherwise she would be unable to complain of alien movements, thoughts, or voices’ (2004: 98). Recent evidence suggests that alien experiences are potentially understandable in terms of prior (historical) traumatic childhood events (Read et al., 2005). In pre-modern societies, unusual experiences, such as hearing hallucinated voices, were not necessarily seen as abnormal phenomena, and other interpretations (e.g. the actions of gods or spirits) were more readily available (Leudar and Thomas, 2000).
The concept of mental illness mystifies by explaining a woe as something that is caused by a bodily disorder. The alternative outlined by Rego (2004) is to transform a distressing experience into a phenomenon with which a person can grapple as an objectified element within their total personality. Of course, a person still has to contemplate making a change and to act upon it. This raises the question of whether it is reasonable to assign responsibility (to the affected person or to others) and whether the parties actually have the freedom and power to act. At the two ends of a continuum of power, we have Szasz’s ‘free will’ and, at the other, the social/materialist position of authors such as Smail (2005) and the Midlands Psychology Group (MPG, 2014).
Smail argues that ‘there is no such thing as an autonomous individual’ (2005: 46), and he regards the client/patient as a victim who lacks the resources to combat external power in all its forms. He thinks that a therapist can, at best, support, comfort, and possibly help to articulate the state of affairs in which the person finds herself. This view seems to underestimate the extent to which anyone described as mentally ill can exercise their agency and powers of reflection. Szasz’s position (that people by default are morally accountable for all of their acts) errs in the opposite direction. As Schlick (1939) theorised, the power of agency and rational self-governance are acquired in childhood, and in Western societies this learning is non-optional. Few concessions are made to adults however adverse their early education or later social environment has been. Autonomy and the ability to change are our default assumptions even though their fit to reality is approximate. Some people simply take their own life when change seems impossible. In the UK population survey cited above, 4 per cent of men and 7 per cent of women reported either self-harm or suicide attempts (NHS, 2015). Suicide is the leading cause of death among young people (WHO, 2001).
The Midlands Psychology Group (MPG, 2014: 124), like Rose (1999), are suspicious of the ideology of autonomy (free will), and follow Michel Foucault in seeing it as a product of the social, historical, and material circumstances in which we find ourselves. They maintain that ‘distress is not the consequence of inner flaws or weaknesses’. If that is so, it excludes entirely any question of moral accountability (MPG, 2014: 123). However, MPG accepts that people often view their distress in moral terms and they point out that ‘experience and explanation are two very different things’ (ibid.: 124). I take this to mean that a belief in personal autonomy is, from their standpoint, a form of false consciousness, a position similar to the one I outlined earlier that ‘free will’ has mythical elements. However, a belief in free will is not ‘false’ in the sense implied by MPG because it can be cultivated and rendered effective. In support of their position, MPG point to a correlation between woes and a person’s level of material resources, class, gender, and other forms of social inequality.
The consciousness of freedom may be false in the sense that it reflects a political ideology (i.e. it is mythical and constructed rather than a natural endowment), but the fact remains that we live in a society founded on a belief in autonomy and freedom of choice. In the absence of a worked-out political alternative, any criticism of the status-quo acceptance of autonomy lacks credibility and force. Although social arrangements reliant on a belief in free will can lead to manifestly unfair outcomes, people are unlikely to prefer to be governed through more transparent forms of coercion or to want to return to a pre-modern belief in malign forces. It does a client or service-user no favours (given the social contingencies they have to face) to regard them as a victim who has little power to resist or change. In fact, this attitude could be said to reinforce the social messages they have already received about powerlessness.
In practice, MPG reverts to a belief that therapy and/or medication can foster a person’s reasoning and agency, e.g. ‘help people make better use of the powers and resources already available to them’, ‘draw attention to unrecognised resources’, and ‘explicitly support people to cease viewing themselves as ‘the problem’ (2014: 134). They observe that clients particularly value listening, understanding, and respectfulness. ‘Respect’ is as much a product of a political philosophy of autonomy and volition as it is an ideological support for a welfare policy that is engineered to make the individual feel personally responsible for their woes. Rose (1999), Smail (2005: iv) and Foucault (see Oksala, 2005) all seem to endorse a concept of freedom that goes beyond, and is incompatible with, their main theoretical presuppositions. The paradox is that a sense of freedom is both acquired and maintained as a consequence of being exposed to external sanctions, including punishment. At the same time, our sense of freedom seems to include an element of non-restraint whose source remains elusive.
When the status of being a free moral agent is assigned by default, for an adult to claim otherwise requires special pleading. However, because the process of acquiring agency is largely invisible, there may be a failure to respond sympathetically when a person does not act according to common norms of what is reasonable and morally justifiable. Society can adopt at least two positions to reconcile deviant behaviour with the presumption that a person should be accountable for their acts. The first is to suppose that the presence of a so-called mental illness removes the obligation or explains the deviation (see earlier discussion). The second position amounts to various degrees of disapproval and censure combined with re-education. This response comes naturally when a person does not demonstrate ‘strength of character’ or ignores the feelings and wishes of others. Incomprehension applies especially to people given a diagnosis of personality disorder. Their non-conformity is usually episodic and, being unexpected, it may catch others off-guard. As a Department of Health information booklet explains it: ‘We may find ourselves feeling uncharacteristically frustrated with someone, or eager to help and “rescue” them from their difficulties, or feeling we have to tip-toe around them for fear of provoking them’ (Tavistock and Portman NHS Foundation Trust, 2017: 4).
Therapists who work with people given this diagnosis have to train themselves to suppress their spontaneous responses of annoyance or disapproval (Linehan, 1993). The ‘natural’ reaction to someone who violates the norms of social interaction points to the function that these reactions serve in enforcing social conformity. In other words, disapproval or censure, besides being social judgements, can be understood as having a natural causal effect on a person’s behaviour. Contrariwise, a person’s resolve, and consequently their power of agency, can be strengthened by praise and encouragement. In a society founded on the concept of a person as a free agent, we have no option but to approve or disapprove when we feel it is justified. If we did not do so, the functional integrity of this social arrangement would presumably break down.
Abolishing the concept of mental illness would not remove a need to evaluate, and in some cases attempt to modify or sanction, behaviour that creates a problem for self or others. Debates about deviancy would simply revolve around different criteria. These are likely to include the probable success of non-coercive measures, human rights, and risk to other people, in so far as this can be ascertained. At present, society’s response to behaviour that confounds social expectations often gives out a mixed message about responsibility and ‘illness’. This is nicely illustrated in the journals of a man diagnosed with schizophrenia in the 1960s who spent most of his adult life in psychiatric hospitals (Hallam and Bender, 2011). On the one hand he was diagnosed as ill, accepted his diagnosis, swallowed his pills, and was puzzled by experiences that were clearly puzzling:
The delusion to which I am referring is simply this. I was hearing voices, and for a long time assumed them to be some form of hallucination. But, just as a strong man can be broken with the dripping tap torture in five minutes used during the last war, so these voices – repeating everything I said and making comments (sometimes obscene) eventually drove me into the false belief that they were real.
Hallam and Bender, 2011: 225
On the other hand (and in that era), he had to contribute to the cost of hospital care out of his welfare payments and to deal with his own tax affairs. He was assumed to be capable of taking advantage of industrial rehabilitation and to find a job. At various times, he was regarded simultaneously as ‘lazy’ and ‘ill’. When being interviewed for a job (while residing in hospital), he said that he suffered from ‘mild schizophrenia’. This lost him the job and his mental welfare officer was completely furious with him for having mentioned it (ibid.: 141). For this young man, the concept of mental illness confused what was already a puzzling state of mind, and he received mixed messages about how to act responsibly. By mentioning ‘mild schizophrenia’ at his job interview, he was being quite reasonable in his own eyes, either deliberately torpedoing his chances of getting a job or alerting his potential employer that he could not be relied upon 100 per cent of the time. This illustration is taken from a different era, but there is little reason to suppose that mixed messages about personal responsibility have not persisted with respect to the ‘mentally ill’.
The position taken by professionals engaged in therapy or rehabilitation is to encourage people to be more responsible for their actions so that they conform more and deviate less. For instance, interventions are presented as interpersonal strategies designed to enhance responsible self-governance (Rose, 1999). To be consistent with the myth of free will, engagement with them has to be seen as freely and voluntarily undertaken. As this is expressed in the ethical code of the British Psychological Society, all practising psychologists must ‘value the dignity and worth of all persons, with sensitivity to the dynamics of perceived authority or influence over clients, and with particular regard to people’s rights including those of privacy and self determination’ (BPS, 2009: 9). In practice, this means that any practitioner must obtain informed consent, keep confidential notes securely, and register as a data controller with the Information Commissioner’s Office. The function of this code of ethics is primarily to protect a service user’s/client’s human rights. The aim of non-coercive methods is to return a person to a state of self-determination (free will).
‘Responsibilizing’ welfare policies are a counterpart to a political concept of freedom. Rose sees them as a disguised form of social control (Rose, 1999: 54). The objective is to foster freedom by appearing to reinforce the positive value of autonomy while in practice it serves to strengthen conformity to norms that are mostly promoted by the State, by experts, and by mental health entrepreneurs. As Rose points out, it is not only governments but also radical political thinkers who have advocated a style of existence in which a person works upon him/herself in the name of freedom. Authenticity and self-expression are usually celebrated. Rose sees the policies of advanced liberal governments as having developed from the aim of ‘freeing’ people in the realms of the market, civil society, and the family: ‘The private conduct of free citizens was to be civilised by equipping them with languages and techniques of self-understanding and self-mastery’ (ibid.: 69). Expressed differently, the good citizen ‘would govern themselves through introspection, foresight, calculation, judgement and according to certain ethical norms’ (ibid.: 78). With regard to policies on health, ‘individuals are addressed on the assumption that they want to be healthy, and enjoined to freely seek out the ways of living most likely to promote their own health’ (ibid.: 86). Rose believes that this has encouraged a view of health as consumption, where choice is influenced by experts, by entrepreneurs of the health market, and by advertising.
At first glance, a consumerist approach to mental health is congenial to the policies of advanced liberalism. However, there are some rather obvious mismatches with reality on the ground. As a consumer, a person is only relatively autonomous because she/he is not an isolated agent who can choose regardless of the interests of family, friends, or employer. In any case, a person might be mystified as to what choices are available to them. It would be stretching the facts to say that most people are informed consumers as far as their own mental health is concerned.
There have been moves in the UK to give greater personal control and choice over care received. This has taken the form of direct State funding of a personal budget for people with long-term health or social care needs. The budget is an agreed amount of money that is planned in conjunction with a health professional. This is only a limited form of consumer choice because there is a lengthy application procedure and spending has to be approved in the light of explicit goals. As expressed by the charity, Rethink: ‘It can be difficult to find the balance between someone being well enough to make decisions about what they need whilst also having severe enough needs to meet high eligibility criteria’ (Rethink, n.d.).
The demand for a personalised service came initially from service-users who wanted to have more say in what was being offered to them (Beresford, 2013b; Weinstein, 2014: 12). This fits with a consumerist philosophy but the government decided to impose this model for whomever it is eligible, whether or not it was wanted or appropriate. Genuine consumer choice is rather limited within statutory services. For example, service-users are rarely able to choose their key worker or therapist.
In practice, it is mental health and social welfare managers who are the consumers and make decisions about how to spend their resources. They need suppliers who offer products that can be operationally defined and counted. The managerial approach is accompanied by a drive to reduce costs and increase the predictability of operating procedures. Problems are specified in standard ways, functions are compartmentalised, and there is strict control over processes, such as the permissible number of sessions. Uniform outcome measures are adopted, allegedly for the purposes of quality control. None of this is conducive to consumer choice. To allow genuine consumer choice would mean providing a wider range of options and alternative ways of conceptualising problems that take greater account of their uniqueness. Target setting with simple measures encourages a distortion of good practice, such as maximising throughput using a narrow definition of outcome. Examples of these effects in community mental health services are given by Moth (2014) and Brammer (2014), and for counselling and psychotherapy in the National Health Service by Proctor (2015).
Rationalisation occurred earlier in the United States and with some clearly undesirable consequences. Managed Care Organisations (HMOs) and private health insurers have adopted psychiatric diagnosis as the basis for approved funding. Cushman and Gilford point out what a profound influence this is:
Whoever controls the delivery of mental health care – by determining such things as the definition of mental disorder, triage criteria, and the nature and length of proper treatment – inevitably and deeply affects society-wide understanding of health and illness, abnormality and healing, the possibilities and limits of human nature and thus what is believed to be proper and good.
Cushman and Gilford, 2000: 985
They note that the consumer taking advantage of their insurance scheme may have little choice on what is offered. Some HMOs ‘require their clients to sign treatment contracts that state that non-compliance can be grounds from dismissal from the HMO treatment benefit’. Alternatively, in the face of non-compliance, they may ‘invoke a more pejorative diagnosis’ such as personality disorder that is not reimbursable (ibid.: 988).
The distortion of a concept of mental health to force it in line with an aim of decreasing dependency on welfare is evident in UK government publications (see Chapter 8). Many service users/survivors who took part in a recent consumer survey (Beresford et al., 2016) felt that the idea of ‘recovery from illness’ had been subverted by government policy. For them, it had come to be defined in terms of people coming off benefits and getting a job, rather than improving their life chances.
Rose is sceptical of ‘responsibilizing’ forms of social control but he does express an opinion, rather sketchily articulated, on ‘genuine’ responsibility and freedom of choice. He mentions volunteers with a radical agenda who operate outside bureaucratic structures. He also notes that expertise is sometimes generously shared. He refers to ‘bereavement counsellors who cluster around events from the illness of a child to the experience of a plane crash’ (Rose, 1999: 91). Having argued that freedom is relative, historical, technical, and tied up with power and subordination, Rose is led to abandon the idea that ‘subjectivity is privileged as the authentic and natural locus of moral autonomy’ (ibid.: 95). If his were to be a complete account of subjectivity, a person would have no compass at all to give them a sense of direction, apart from the advice of experts and State regulators. Nevertheless, given the corner into which he has driven himself, Rose does ask how we can ‘orient ourselves to the value of freedom’ (ibid.: 95). His tentative answer is ‘to value all stratagems, tactics, and practices that enhance human beings’ capacities to act’ (ibid.: 97). The values underlying Rose’s position are therefore unclear. He would ‘evaluate practices in terms of the extent to which they accord those caught up within them the capacity to judge, accept or transform the practices that subjectify them . . . to be open, inventive, and questioning’ (ibid.). These sentiments, which could certainly be understood as a clarion call to anyone seeking alternatives to present mental health services, seem to give back what he has already taken away theoretically.
The assumption that mental illness ‘exists’, and needs a mental health service to deal with it, creates an expectation that the State should attend to everyone’s ‘mental ill-health’. However, it is quite evident that physical health and mental health do not receive equal attention or funding. This is understandable inasmuch as the circumstances to which mental illness refers are elastic and unquantifiable. Abandoning the concept would at least allow a cooler appraisal of the likely causes and promising solutions for each type of woe, leading to a better appreciation of where responsibility should lie – whether with the individual, with the community, with the State, or with these sources of agency acting together.
So-called mental illnesses are somewhat more reactive to events than many physical illnesses. The cause of a physical illness might, of course, be accidental or unforeseen but once diagnosed, plans can usually be put in place to deal with future contingencies. Treatment can sometimes be delayed. For so-called mental illness, immediate and timely action is often crucial. Even for those people who are regarded as having a ‘long-term mental illness’, unforeseen crises can arise which require immediate attention. Weinstein (2014: 22–24) gives the example of a man who disturbed his neighbours in a community setting and shows how the crisis needed to be understood (and assessed) from at least half a dozen angles, each with a different implication for the urgency (or otherwise) of taking action. Even for a person who is generally functioning well, it makes no sense at all to wait weeks or months for an appointment with a mental health professional. Prompt action is more likely to lead to a resolution, allowing a person to return to work or cope with a crisis. A person might have reflected for some time before seeking help but, even then, the time window for acting and making a change is usually narrow.
Although the State is necessarily involved in responding to at least a proportion of people in distress, there are several objections to framing this social obligation as a response to mental illness:
(1) The accountability of the State and the individual is not at present transparent or made explicit (i.e. there is mystification about causes and responsibilities).
(2) Assigning responsibility to the State for the rectification of woes (e.g. the provision of treatment for ‘mental illness’) runs the risk of downplaying the role (and human rights) of the individual. It should be possible to devise other interventions that are less coercive and permit a person to overcome their woe through their own efforts or jointly with others.
(3) If each type of woe has characteristic causes and needs to be resolved in a variety of ways, there is little to be gained by assuming that ‘mental illnesses’ have anything much in common. The ‘mental health system’ is to a large extent already a collection of unrelated activities and functions.
(4) The response of mental health services is often inordinately slow and inflexible, and being slow or untimely, any intervention is less likely to be effective. In many cases, it is the police service that deals with emergencies.
Recent recommendations to the UK Government from a Mental Health Task Force (MHTF) (DOH, 2016) include a call for parity between physical and mental health services, and don’t hesitate to inflate the need:
We know that the scale of unmet mental health need is significant – hundreds of thousands of people go untreated each year at a cost of billions of pounds to our society and the economy . . . The whole NHS plays a role in preventing mental health problems and caring for people who suffer them.
DOH, 2016: 66
That there are unmet needs cannot be questioned, but the language of treatment, caring, and suffering may be inappropriate. People may not want to be labelled as mentally ill or receive ‘treatment’ from the State. To seek help or advice from this source places a person in the position of a supplicant. A supplicant is defined as someone who asks humbly for something from a god or person in authority. For a person whose problems may well have originated in coercive parenting or abuse of various kinds, a sense of agency may not be best cultivated by providing ‘treatment’. The MHTF implicitly confirms the one-down position of a service-user when they state: ‘This is critical in enabling people with mental health problems to play a more active role in making choices about all aspects of their care, based on a more equal and collaborative relationship between the person and professional(s)’ (ibid.: 43).
The illness myth accounts for why some people act in ways that disturb others and why they demonstrate an inability to solve their own woes. The myth can be viewed as a form of mystification that attributes the reasons for these failures to conform to a person’s ‘illness’ or ‘disorder’. This account de-emphasises the part played by social processes in causing and maintaining woes. The myth is supported by strategies to rename mental illness as ordinary distress or impairment. The belief that mental illness is ‘just like any other illness’ reinforces the myth. In effect, campaigns to de-stigmatise ‘mental illness’ conceal the circumstances that produce woes. One effect of abolishing the concept of mental illness would be to reveal rather than hide the significance of social appraisal and control. Abolition need not carry the implication that people should (in general) be made to feel more or less responsible for resolving their woes. The case for abolition presented above is framed within a deterministic theory of the acquisition of agency, in which ‘free will’ is viewed as a useful myth that serves to organise social relations. This framework is used, in turn, to throw light on the process of regaining self-control in therapy, on social policies that stress individual responsibility, and to inform a rationale for the future provision of well-being services.
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