Insights from Szasz and Wittgenstein on the distinction between disease and behaviour, and the political implications of abandoning the medical model

Joanna Moncrieff, Soon-to-be-Professor, University College London, Consultant psychiatrist and chair person f the Critical Psychiatry Network London, SIG conference, Sept, 2019 “It was the brain tumour what done it!” , 1920-2012 • Depression is ‘a real illness. It is not a sign of a person’s weakness or a character flaw’ (NIMH, 2018)

• ‘Depression and anxiety are real illnesses – not character flaws’ (depression blog, 2018). The differences between disease and behaviour Disease Behaviour A material thing Not a material thing- what some material things (organisms) do

A ‘property’ of tissues, cells or physiological An ‘activity’ of whole, living organisms processes

Unfold following the ‘laws’ of biological systems Initiated by the individual

Not directly amenable to individual’s will Is an expression of the individual’s will (desires (although can be indirectly influenced by such) and purposes)

Relatively predictable Inherently unpredictable Subject to causal laws Not explainable in terms of causal laws

Meaning is independent of social context Meaning is dependent on social context

Can be described ‘objectively’ (independent of Cannot be described objectively status of observer)

Responses to Szasz

1. Mental disorder can be aligned with physical disease- either due to similarity of psychological and biological processes, or due to similarity of mental disorder and disease (e.g. that both are negatively valued).

2. Mental disorders are bodily diseases and therefore different from other, ‘ordinary’ behaviour Peter Hacker Ludwig Wittgenstein, 1889-1951

“The human body is the best picture of the human soul,” The Investigations, 1953. • ‘Mind’ is ‘the sum total of what a person does and says’ (Szasz, 1996, p. 19) • ‘Naturalists:’ psychological states are objective things like other diseases (Boorse; Wakefield)

• ‘Evaluative’ approach: all disease or illness is defined as being dysfunctional or unwanted- therefore never a strictly objective concept. Therefore mental disorder qualifies as a disease/illness (Sedgewick; Fulford) Example: hypothyrodism Wittgenstein

“Madness doesn’t have to be regarded as an illness. Why not a sudden – more or less - change of character?” Culture and value, 1970, p.62.

“Everybody is mistrustful, and perhaps more so towards their relations..why shouldn’t somebody become much more distrustful of other people? Why not much more withdrawn?...If someone is wary even in ordinary life, why shouldn’t he - and perhaps suddenly - become much more wary? And much more inaccessible?” Culture and value, 1970, p.62. Adolf Meyer, 1866-1950

• ‘The supposed disease back of it all is a myth and merely a self-protective term for an insufficient knowledge’ 1948 p 174 So what is depression? Adolf Meyer

• With the disease model, the doctor ‘surrenders his common sense attitude’ and fails ‘to view the abnormal mental trend as a genuine but faulty attempt to meet situations, an attempt worthy of being analysed’ 1948, p 136 The political implications of rejecting the disease model

• Entitlement to care and resources • The justification of control or coercion • Personal responsibility Recovery as self-transformation

• ‘my old self had to die in order for my new self to emerge. I had to forge a new normal, one excruciatingly painful day at a time.’ (B05).

• ‘A practice of gratitude puts a salve on the wounds of depression. It’s not a panacea. Not by a long shot. But, it’s part of a multi-faceted solution for what ails us. It’s a way of taking back the steering wheel of our lives from depression. We can choose to consciously ponder the good things in our lives. It’s a choice. It’s deliberate. And it’s empowering.’ (B06) Personality modification and the politics of psychiatric drugs

Joanna Moncrieff, SIG conference Sept 2019

Accepted view is that drugs correct an underlying biological abnormality – a “normalising effect” (Davis 1980)

Chemical imbalance Abnormal neural circuitry • ‘imbalances of certain chemicals in the brain are thought to lead to the symptoms of the illness. Medicine plays a key role in balancing these chemicals’ Pfizer, 2006, on Models of drug action Disease centred model Drug centred model

Drugs correct an abnormal brain Drugs create an abnormal/altered state brain state Drugs target specific diseases or Psychiatric drugs as psychoactive abnormalities drugs Therapeutic effects of drugs arise Useful effects are a consequence of from their effects on disease drug-induced changes to normal pathology or the biological brain functioning mechanism s that produce symptoms Example (general medicine): Examples: alcohol for social anxiety, asthma treatments, insulin for opiate anaesthetics diabetes, aspirin, paracetamol Psychoactive drugs

• Altered mental states: produce changes in normal cognition, emotion and behaviour

• Linked physical alterations (eg drug-induced sedation has mental and physical components) People have used psychoactive substances to alleviate misery for millenia

Neuroleptics were widely advertised for agitation in the elderly and behavior problems in children up to 1970s Specificity of neuroleptics

• “they appear to do more than tranquilise” (Henderson & Gillespie 1962).

• “the drugs penetrate much closer to the site of mechanism of the disease itself than any other procedure applied hitherto” (Mayer-Gross, Slater, & Roth 1960).

Specificity of

• antidepressants “appear to act specifically against depressive symptoms” (Dally, 1967)

• “much more specific” than ( conference 1962, Goldman, (1966), Views about how psychiatric medicines worked changed from the 1950s onwards, and the disease-centred model was adopted.

Pre 1950s- drug Post 1950s- disease centred: centred: • • Antidepressants • Sedatives • Anxiolytics • Mood stabilisers • Stimulants • Hypnotics • Treatment resistant This transformation does NOT occur because of accumulating evidence for the disease-centred model

There was, and is, very little support for the disease-centred model (the idea that drugs target underlying abnormalities)

Placebo controlled trials do not distinguish disease- centred from drug-centred model • But- in reality drugs are still aimed at people who are dissatisfied with how they are and how they feel and want their normal state to be changed: Huxley

• “The need for frequent chemical vacations from intolerable selfhood and repulsive surroundings will undoubtedly remain. What is needed is a new drug which will relieve and console our suffering species without doing more harm in the long run than it does good in the short.”

Implications of different models of drug action: the disease-centred model

• Drugs reverse or ameliorate an unwanted biological process or ‘disease’ that gives rise to symptoms • Any difference of opinion about the value of treatment per se (disregarding differences over overall balance of pros and cons) is likely to be due to the effects of the underlying condition and quite separate from the individual’s core views and values Implications of different models of drug action: Drug-centred model

• Drugs change ‘normal’ mental processes (e.g. thoughts and emotions) and behaviour • To the extent that they target abnormal mental and behavioural events, they do so because they change those sort of mental states and behaviours in general, not because they target the underlying biology (e.g. reducing paranoia by reducing sensitivity and motivation in general) Drug-centred model

• If there is no demonstrated underlying biological process giving rise to the ‘symptoms’ then drug ‘treatment’ can be understood as a means of changing someone’s behaviour or ‘character’ • This can be consensual - many illicit drug users want to reduce their emotional sensitivity and reactivity- and may seek out prescribed drugs for the same purposes • People who seek treatment with antidepressants or tranquilisers may want to experience the alterations they induce, but is it ethical to prescribe ‘chemical vacations’ (Huxley) for this purpose?

• Or it may be non-consensual

• Or, in many cases, it may be incapacitous because people are led to believe drugs work in a disease centred way against an identified underlying disease process, when this is not in fact the case, and when the drugs being prescribed have mind and behaviour altering properties. In other words, prescription of psychiatric drugs may be altering people’s character (patterns or tendency of behaviour) without their informed consent “Rottenly normal” (Oliver Sack’s brother)