Mental suffering: the blurry parameters of medicine

In our western society, the clinical treatment of any psychological unease has become socially acceptable, and even a social norm. It is a notable by-product of the modern-day medicalisation of the mind, which implies that these “mental” problems are akin and juxtapose to physical disorders. The current field of psychiatry operates primarily on conjecture and anecdotal experience, which troubles the clinical boundaries of medical ethics. Consequently, in terms of administering treatment, the philosophical and ethical dialogue of what distinguishes a mental disorder from a somatic one has plagued physicians for decades. Since the medicalisation of these disorders quickly loses traction if it is not done in reference to a normative social context. This dialogue also exposes some social and diagnostic dilemmas in the social understanding of human psychology. To explore these issues, I will discuss the theoretical complexities of locating a definitive category of mental distress, by looking at where it overlaps with somatic conditions. Additionally, I will examine the social inferences of labeling certain psychological states as “disordered”, or as “illnesses”.

Our understandings of the human body have become more invested in, and dependent on empirical medical knowledge and the illusion of precision it offers us. Any mental distress or chronic problem in psychosocial functioning is socially legitimised within this physicalist framework, but it still remains more stigmatised than any physical issue. The field of psychology traditionally denoted a science of the soul, and Aristotle (1986) conceived of it within the broader scientific study of nature. Nevertheless, the modern domain of psychological inquiry has become more refined and in this particular clinical context, the term “soul” can be now understood as being of the mind. For the phenomena in the mind, and what makes individuals unique, exemplifies the “…many specific modules or mechanisms that are designed to respond to specific environmental challenges” (Horwitz & Wakefield, 2007, p. 15). The human mind responds and reacts to external stimuli, some of which are somewhat biologically universal and rational, and some are less so. The medicalisation of psychology attempts to overcome its enigmatic nature and thus the social stigma, by situating mental understandings in a biological design. It tries to characterise it as similar to physical occurrences, in reference to some anatomical structure. But since every human attempt at describing it reveals the limitations of human understanding, the existence of individual consciousness  troubles this medicalisation of a mind-body separation. (Nagel, 1974, p. 435).

Although neurological knowledge has revealed all the inner experience in our minds are ordered and structured, in some way by objective and biochemical events, it is still ambiguous whether they are merely symptoms of our bodily functions, or a fundamental part of them. The medical classification of illness, while it apparently provides a degree of social understanding, it seems to infer that “mental” and “physical” are merely adjectives, describing two kinds of the same thing. Well-known skeptic of psychiatry, Thomas Szasz (1960) reasons that this clinical approach towards atypical psychology and behaviour, only serves to lessen the social “…burden of understanding…” on society (p. 177). The distinct category of “illness” indicates some abnormality in a biological function that gives rise to secondary disordered symptoms, but currently mental illnesses do not fit comfortably into this category, because they are just a collection of symptoms.

Unlike physical illnesses, the biology of psychological processes and the exact causal correlations are still largely unknown.  Also the American philosopher Thomas Nagel (1974)  aptly points out that what is known about neurology does not even elucidate the somatic aspects of consciousness (p. 437) . Consequently, it is incongruous that any deviations, in consciousness, from an arbitrary functional mental norm can now be classed as an illness, and thus any persistent mental struggles are viewed to be only truly alleviated by medical treatment. While she does not discredit this supposition, moral philosopher Nomy Arpaly (2005) says mental states interact with social reality, in a way that physical states do not (p. 283). Yet the medical conflation of physical and mental dysfunction operates to reinforce that mental aptitude and emotionality have an elusive biological standard, like our physiology.  According to Arpaly (2005) this creates a cultural-based distortion of emotionality, which can be used to biologically frame any particular “undesirable mental state” as dysfunctional. Mental disorders differ from physical conditions, in that they are not just faults in biological mechanics, often they are about something, in that they have meaningful content that is not readily accessible to others (p. 285).

The Diagnostic and Statistical Manual of Mental Disorders underplays the meaningful aspect, the individual context and causes in diagnosing an illness, instead it concentrates on the problematic symptoms. Sociologists, Allan Horwitz and Jerome Wakefield (2007) say that without taking into account the possible social and cultural causes for biological changes, we cannot delineate what is disordered and what is not. Since we do not have “….a baseline for judging some cases as clear examples of normality and disorder…” (p. 16). In contrast to treating a purely corporeal condition, it is not quite appropriate to use a general clinical or behavioural criterion to classify any particular psychological state. That is unless an objective physiological equilibrium can be established, or the criterion encompasses the patient’s functionality and “warranted” mental states within their individual context.  As the way psychiatry operates presently is very much tied to subjective judgements and therefore often mistaking social issues for medical ones, and possibly vice versa.  Many academics have said that this can obscure, subtract, and decrease our understanding of, the particularities of any human experience (Arpaly, 2005, pp. 288-290; Nagel, 1974, pp. 444-445; Szasz, 1960, p. 116).

Furthermore, in viewing mental distress as always primarily medical, it bolsters the cultural norms of individualised emotionality and mental states, and sidelines the collective and societal influences. Agreeing with Arpaly’s assertion about “…undesirable states…” , Horwitz and Wakefield (2007) argue that this medicalisation frames how we view mental functionality (p. 7-8) and, as Szasz (1960) also says, what ideas and behaviours are socially acceptable (p. 116). By pathologising what is deemed socially abnormal or deplorable, it allows us to not scrutinise these value judgements, while believing there is a unanimous psychological norm. The focus on the biological and chemical processes,  Horwitz and Wakefield (2007) say, has come “…at some cost to validity…” in correctly labelling certain mental phenomena as disordered and therefore abnormal (p. 8). However, labels are practical, to be able to define such an issue in medical, ethical and legal terms, helps us socially manage this type of dysfunction.  It performs to superficially localise the suffering and therefore “troublesome defect”.  It is still“a convenient myth” though (Szasz, 1960, p. 119), because an universal mental equilibrium has not been found as yet, and so any diagnosis is reliant on subjective judgement . Calling any mental anomaly an illness provides comfort, to be able to classify any chronic and harmful problem in the mind as linked to biological processes, some shameful onus of one’s own distress is removed.

However, meaningful psychological events, ie. consciousness, are another way that individual subjectivity is exposed, but not always one’s pathology, because mental activity reveals that there is always an interiority to experiences. This is the phenomenal aspect, that Nagel (1974) calls a particular state of mind. It encompasses our mental substance and demarcates it as not sharable or observable, and only understandable from similar perspectives (p. 436). It is interesting to note that Aristotle (1986) initially defined the human psyche similarly, as the capacity of moving in and perceiving its surroundings in reference to itself. It is also deeply entwined with our personality, identity and thus cultural value. So by describing this subjectivity as an illness, without knowing the biology behind it, possibly medicalises social issues and diverse personalities (Szasz, 1960, p. 114). These social aspects may be why a mental diagnosis carries with it social stigma in a way that a physical one does not.

These mental capacities are performed through, and proximate to the physical body, and manifestly comprises our internal experience of the outer world. Any physicalist analysis of what is mental phenomena, as Nagel (1974) rationally asserts, “…will be falsely posed”, unless it addresses the subjective andexperiential components (p. 437). These phenomenal characteristics, such as perception, memory and how we understand our individuated bodies, are subjective and not easily reduced to somatic expressions. Significantly, the Psychology traditionally denoted a science of the soul, and Aristotle (2001, p. 4) conceived of it within the broader study of nature. Nevertheless, the domain of psychological inquiry has become more refined and in this particular clinical context, the term “soul” can be now understood as being of the mind. Since the mind exemplifies the “…many specific modules or mechanisms that are designed to respond to specific environmental challenges” (Horwitz & Wakefield, 2007, p. 15). Consequently, Arpaly (2005) reminds us that “abnormal” mental states occur within, and can be entangled with, a social context. So in pathologising emotional and cognitive states, and not considering the environmental factors, it serves to remove some agency of the individual and societal dimension of all psychological occurrences.

Psychology traditionally denoted a science of the soul, and Aristotle (2001, p. 4) conceived of it within the broader study of nature. Nevertheless, the domain of psychological inquiry has become more refined and in this particular clinical context, the term “soul” can be now understood as being of the mind. Since the mind exemplifies the “…many specific modules or mechanisms that are designed to respond to specific environmental challenges” (Horwitz & Wakefield, 2007, p. 15). Consequently, Arpaly (2005) reminds us that “abnormal” mental states occur within, and can be entangled with, a social context. So in pathologising emotional and cognitive states, and not considering the environmental factors, it serves to remove some agency of the individual and societal dimension of all psychological occurrences.

Psychology traditionally denoted a science of the soul, and Aristotle (2001, p. 4) conceived of it within the broader study of nature. Nevertheless, the domain of psychological inquiry has become more refined and in this particular clinical context, the term “soul” can be now understood as being of the mind. Since the mind exemplifies the “…many specific modules or mechanisms that are designed to respond to specific environmental challenges” (Horwitz & Wakefield, 2007, p. 15). Consequently, Arpaly (2005) reminds us that “abnormal” mental states occur within, and can be entangled with, a social context. So in pathologising emotional and cognitive states, and not considering the environmental factors, it serves to remove some agency of the individual and societal dimension of all psychological occurrenceoverlap in our psychological and physiological spheres, exposes the word “mental” as slippery and not so easy to define. There is an intrinsic obscurity, and yet the undeniable pervasiveness, of these internal processes that constructs our experience of the world. It could never be captured in even the most accurate physicalist explanation (Nagel, 1974, pp. 445-446).

Psychology then seems to constitute the finite subjectivity of being human, and volatility of all mental phenomena. This is why Szasz (1960) is adamant psychiatry medicalisies social conflicts and unrecognised needs in our society, it allows the myth of human conformity and the status quo to be somewhat naturalized and to go unchallenged (p. 117). He strengthens this claim by saying all occurrences of mental disorders are just “problems in living”, so they cannot be defined as illnesses. Although this is not an unfounded claim as Horwitz and Wakefield (2007) show,  because our mental states shape the way we, as individuals, operate socially, some mental features are damaging and a hindrance to personal functioning, without an apparent cause or context. That is where Horwitz and Wakefield (2007) say the classification of “disorder” is appropriate,  that it is the context that allows “abnormality” to be delineated (p. 14). But it is crucial to realise that even if the dysfunctionis rational and warranted responses to everyday life events, that “…does not by itself imply that it is not a disorder or that there is no reason to treat it…” (Arpaly, 2005, p. 285).

Although when encountering any dysfunction or hurt, the distinction between normal and disordered mental states seems cursory, it is very appropriate when selecting a course of treatment which is going to be the most effective. Additionally, in getting a clear definition of what substantiates a “mental” disorder, it would expand social understandings of emotionality and personality.  In this way, it would assist in recalibrating ways to perceive mental functionality and suffering, which are not medicalized (Horwitz & Wakefield, 2007, pp. 22-23). Interestingly, while Szasz (1960) seems to advocate greater social understanding and empathy of diverse behavior and suffering, he asserts that the body takes precedence over the mind. He reinforces the social need to understand the causes of a particular anguish, before treating it. But it is dangerous and impractical to say mental pain does not deserve the same medical management, just because no somatic foundations for this anomaly have yet to be substantiated in reference to a biological equilibrium. Similarly, only viewing these issues as social does not appreciate the very real distress of such a chronic dysfunction, as being on individual lives, not just exposing a societal flaw in understanding and addressing these occurrences.

Therefore, it is useful to not try to demarcate what is a “mental illness”, as we can neither definitively define what is mental or whether unusual states of the mind are illnesses.  Trying to position mental events solely within the physical realm, currently is not productive in treating individual dysfunction. While this physicalist move in psychiatry has been guided by the understanding of neurology and helped the development of effectual psychological drugs, it risks removing the complexities of the human experience. Even if problems in consciousness are able to be unequivocally explained in physical terms and linked in psychochemical processes and could be exclusively physically rectified. It would dehumanise people and not validate the meaningful and incorporeal content of experiences.

Works Cited

Aristotle. (1986). De anima (H. Lawson-Tancred, Trans. H. Lawson-Tancred Ed.). Harmondsworth, Middlesex ; New York, N.Y. :: Penguin.

Arpaly, N. (2005). How it is not “Just Like Diabetes”: Mental Disorders and the Moral Psychologist1. Philosophical Issues, 15(1), 282-298. doi:10.1111/j.1533-6077.2005.00067.x

Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness. New York: Oxford.

Nagel, T. (1974). What is it like to be a bat? The philosophical review, 83(4), 435-450.

Szasz, T. S. (1960). The myth of mental illness. American psychologist, 15(2), 113.