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“It Was the Brain Tumor That Done It!

” Szasz and
Wittgenstein on the Importance of Distinguishing Disease
from Behavior and Implications for the Nature of Mental

Joanna Moncrieff

Philosophy, Psychiatry, & Psychology, Online Advanced Publication, (Article)

Published by Johns Hopkins University Press


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“It Was the
Brain Tumor
That Done It!”
Szasz and Wittgenstein
on the Importance of
Distinguishing Disease
from Behavior and
Implications for the
Nature of Mental
Joanna Moncrieff

ABSTRACT: The current article looks at the distinction evidence of an underlying disease. Attempts to expand
between bodily conditions, such as diseases, which the concepts of illness and disease by separating them
may affect behavior, and situations that comprise self- from their bodily context, to accommodate mental
directed behavior. This distinction was emphasized by disorders within a medical framework, only denude
the late Thomas Szasz, who recognized that regarding the terms of any distinctive meaning. Wittgenstein, like
a situation as a disease or illness has important conse- Szasz, suggests that what we characterize as mental ill-
quences that flow from the association of these concepts ness, therefore, refers not to an illness or disease, but
with the body. Wittgenstein’s critique of the concept of to patterns of unusual but still essentially self-directed
mind helps to clarify and support Szasz’s intuitions. Both behavior. These patterns can be understood as aspects
Szasz and Wittgenstein suggest that we misunderstand of character, although they have a complex relation-
the nature of ‘mind,’ and that mental states and events ship to agency. The implications of this analysis for the
are not independent entities that can be discovered and justification of psychiatric coercion and the treatment
described by natural science, but activities of living of common psychological complaints are explored.
human beings that are manifested in, and recognized
KEYWORDS: Disease concept; Mental disorder concept;
through, forms of public behavior. Mental disorders,
Szasz; Wittgenstein philosophy of mind; Medical model
which are also manifested in behavior, cannot, therefore,
of mental disorder
be aligned with biological conditions, unless there is

© 2020 by Johns Hopkins University Press

2 ■ PPP / Vol. 27, No. 2 / June 2020

n Patricia Churchland’s 2006 essay on free disorder with brain disease. Most, nevertheless,
will, she cites the case of a middle-aged man want to incorporate it into a medical framework.
who, without any prior history of misbehavior, With some exceptions (e.g., Fulford, 1989), recent
suddenly became obsessed with child pornography philosophical debates have avoided the question of
and started to molest his 8-year-old stepdaughter. the distinction between bodily conditions and situ-
He was subsequently discovered to have a brain ations characterized by unusual and problematic
tumor affecting the frontal lobes, and when it is behavior, discussing instead whether mental disor-
successfully treated his aberrant behavior stopped. ders are natural, social, practical or eclectic ‘kinds’
Thomas Szasz is famous for his denunciation (Hartner & Theurer, 2018; Kendler, Zachar, &
of the concept of mental illness, and his critique Craver, 2011; Zachar, 2002) and whether they
is partly responsible for instigating an enduring should be characterized as value-free or value-
philosophical discourse about the nature of mental laden (Boorse, 1976; Fulford, 1989; Sedgwick,
disorder. Szasz’s key insight was the recognition 1982; Wakefield, 1992). A common approach is
that we find it important to distinguish between to incorporate mental disorder into the territory
situations that are characterized by ‘ordinary’ hu- of disease by suggesting some analogy between
man behavior and those that arise from a bodily the biological and psychological realms, thereby
condition or event, such as a disease. Although implicitly or explicitly stretching the concept of
Churchland put it to different ends (to question the disease beyond the body (*Boorse, 1976; *Fulford,
nature of agency per se), from Szasz’s perspective, 1989; Sedgwick, 1982; Wakefield, 1992). This
her example demonstrates the importance of this contrasts with philosophers of science who are
distinction because it shows how we understand not concerned with mental disorder, who often
and respond to pedophilic behavior brought on by simply assume that concepts like disease and illness
a brain tumor quite differently from an ordinary refer to bodily conditions. French philosopher of
criminal case of pedophilia. biology, Georges Canguilhem (2012, p. 35), for
For Szasz, the concept of a disease is essentially example, states that ‘one can speak with reason of
and irreducibly one that applies to the physical “Greek Medicine” only from the Hippocratic pe-
body. It can only be applied to ‘behavior’ when riod onward-that is to say from the moment when
a bodily condition can be understood to be di- diseases came to be treated as bodily disorders.’
rectly driving or causing the behavior in question, Yet, philosophers who take an ‘anti-positivist’
which then ceases to have the characteristics of position have long suggested that it is important
ordinary behavior and can sensibly be described to distinguish how we understand the material
as ‘symptoms’ of a disease, or the result of some world, which includes autonomous biological
other bodily alteration such as that induced by processes like diseases, from our understanding
psychoactive drugs. According to Szasz, human of human behavior. Ludwig Wittgenstein provides
behavior, as opposed to neurological symptoms, an example of this approach, which is rooted in
cannot constitute a disease, because behavior is his powerful critique of conventional ideas about
not a biological entity, and it cannot be adequately the nature of ‘mind.’
explained by the presence of a biological process Szasz has rarely been placed in a wider philo-
(Szasz, 1989; 2000). Because what is referred to sophical context, yet his view of ‘mind’ and its
as ‘mental illness’ consists of problematic behav- relationship to behavior is remarkably similar
ior that cannot be attributed to neurological or to that of Wittgenstein. In this article, I use
pharmacological causes, it cannot legitimately be Wittgenstein’s philosophical analysis to support
thought of as a disease, or a related term such as and clarify Szasz’s position on the importance of
an ‘illness.’ distinguishing between disease and behavior, and
Although prominent psychiatrists claim that the implications this has for how we conceive of,
some or all mental disorders are, in fact, diseases of and respond to, mental disorder. Like Szasz, I sug-
the body, specifically the brain (Insel & Cuthbert, gest that the issue has been neglected because of
2015), few philosophers want to equate mental the strategic benefits of obscuring the distinction
Moncrieff / Szasz and Wittgenstein on the Nature of Mental Disorder ■ 3

and the challenging implications that arise from through words, gestures and actions, all of which
accepting it. derive their meaning through the way they are
used in a public context.
The Nature of ‘Mind’ in The ‘inner’ world of thoughts and feelings is
Wittgenstein and Szasz thus integrally entwined with ‘outer’ behavior;
and behavior is ‘infused’ with the ‘inner’ (Hacker,
Szasz and Wittgenstein express a common view 1997, p. 42). One does not cause the other, they are
that what are referred to as ‘mental states’ or just aspects of one and the same thing! As Wittgenstein
‘mind’ are not properly thought of as ‘internal’ commented, ‘the human body is the best picture
phenomena that can be analyzed using the meth- of the human soul’ (Hacker, 1997; Wittgenstein,
ods of natural science. Thoughts and emotions, 1953), cited in Hacker, 1997, p. 44).
as we normally understand them, cannot sensibly In Philosophical Investigations, Wittgenstein
be described as brain events nor as independent famously gives the example of pain and shows that
psychological events or processes. They are, in- we learn how to use the term ‘pain’ to describe
stead, properties of living human beings that are our own experiences through learning how the
expressed, and made sense of, within particular term is applied to situations in which other people
material and social circumstances and in the con- are said to be in pain. The first person and third
text of individual biographies. person use are indissolubly linked, and the first
Wittgenstein’s later philosophy suggests that, person use to describe a personal experience is
under the growing influence of science, we have only logically possible given mastery of the third
mistakenly come to think of mental attributes as person use, which is based on behavioral grounds
‘things’ that have their own properties, and can be or criteria (Wittgenstein, 1953).
known independently from the sort of organisms Hacker describes how emotions and moods
that manifest them. We see the mind as a separate are also understood through particular public
entity that can be regarded as causing human ac- expressions that form the criteria for ascribing an
tions, just as a mechanical process might cause a emotional state to an individual (Hacker, 2004).
material body to move, or a nervous reflex might Some emotions are demonstrated by an immediate
cause one’s knee to jerk. We have come to under- reaction, like a smile, or expression of surprise,
stand ourselves as beings that are not co-extant and some, like sadness, grief or anxiety, by longer
with, but that have minds, and by doing this we lasting patterns of behavior. Implicit in emotion
introduce an illusory schism between ourselves language is the idea that the feeling is typically a
and our minds. reaction to someone or something. Love, hate,
This position, which arises with Descartes and anger often have as their object another living
and Locke, has become deeply embedded in ‘the being. Surprise and delight are usually immediate
grammar of our languages,’ according to the Witt- reactions to proximate events. Sadness, fear, guilt,
gensteinian scholar, Peter Hacker (1997, p. 14), shame, and happiness are less immediate reac-
and fundamentally distorts our understanding of tions, but also normally understood as responses
the ‘mental.’ In contrast, Wittgenstein and Szasz to something that has happened, is happening or
argue that what we think of as mental events or might happen to someone. Part of the context of
processes, that is thoughts, emotions, attitudes and emotion language is the object or events at which
sensations, are not essentially private and internal, the emotion is directed. In other words, unlike
but are unavoidably manifested in public behavior. physical sensations or physiological states, such as
Indeed, behavior is constitutive of our understand- hunger or pain, emotions and moods, like thoughts
ing of what mental states and processes consist of, and behavior, are usually meaningful.
and particular forms of behavior constitute the Szasz, too, stresses the behavioral aspect of
criteria for our attribution of a mental phenom- mental states or feelings. Like other writers, Szasz
enon to an individual in a particular situation. points out that the noun ‘mind’ is only a few centu-
We express our beliefs, feelings and experience ries old, and Szasz suggests that it would be better
4 ■ PPP / Vol. 27, No. 2 / June 2020

understood in the sense of the old verb ‘to mind.’ thoughts and emotions are not just, or primar-
‘Minding’ can be understood as what human be- ily, private events—whether these are conceived
ings do and how they respond to the world around as taking place in the brain or the ‘mind.’ We
them. Incidentally, Hacker also points out how recognize and identify these situations through
current uses of the noun ‘mind’ can be replaced the behaviors and reactions that people express
by verbs, concluding that ‘mind’ is ‘an oblique publicly, and the context in which these occur.
way of speaking about human faculties and their We can apply this view to the situations we
exercise’ (Hacker, 2010, p. 250). For Szasz, when refer to as mental disorder, such as ‘depression.’
we use the language of intention, belief or emo- There are various patterns of behavior we might
tion we indicate that a person cares about, or has associate with this emotion as broadly conceived.
a position on, something; that they ‘mind;’ and as Someone might take to bed and cease to go about
he points out ‘how and what we mind is who we their everyday life. They might cry easily and
are’ (Szasz, 1996, p. 17). Szasz, like Wittgenstein, display obvious signs of distress. Someone might
suggests, therefore, that mental attributes are become preoccupied with a negative and pes-
not aspects of some mysterious, ethereal object simistic view of the world. Someone may visit a
called the mind, nor of a material object such as doctor or other professional to say that they are
the brain. They are attributes of human beings not feeling ‘right’ and are struggling to cope with
whose behavior is in constant interaction with the their responsibilities, or they may simply say that
social and material conditions of their existence. they are not happy to those around them. When
The ‘mind’ in this view refers to the ‘sum total of we speak of someone as becoming depressed, we
what a person does and says’ (Szasz, 1996, p. 19). imply a change in their behavior. The ‘depressed
Szasz stresses how ‘minding’ is a particularly behavior’ is new; previously the individual was
human characteristic that is an expression of acting ‘normally.’ The important point is that
our rational nature. Being ‘creatures that mind’ the sorts of behaviors we associate with depres-
entails that we evaluate situations and can make sion are not the mere external manifestations of
reasoned decisions about what we do. On this some ‘inner’ state that is what depression really
view, our behavior is a manifestation of our hu- is, whether that is thought of as a brain condi-
man agency, and the concomitant of this is that tion or a private mental state. When we refer to
we can be regarded as responsible for our actions. someone as ‘depressed,’ even when we do this
For Szasz, therefore, the ‘concepts of right and within the framework of diagnostic systems like
wrong, responsibility and mind’ (Szasz, 1996, p. the Diagnostic and Statistical Manual of Mental
43) are closely interdependent. Disorders, we are not identifying the real nature
Like Wittgenstein, Szasz suggests that we have of their nervous system or mental make-up. We
been enticed into regarding human behavior and are talking about the sorts of behaviors they are
mental orientations as a substance, a thing we call displaying, and our normal understanding of how
‘the mind’; ‘we misunderstand “minding” as using these reflect their thoughts, feelings and intentions.
our “mind”’ (Szasz, 1996, p. 17). This separation
of ‘mind’ from the whole living, acting human Understanding the Mental
being enables us to downplay the moral aspects
of behavior. When actions are attributed to the Wittgenstein’s analysis of the nature of ‘mind’
mind rather than the person, responsibility can be is consistent with anti-positivist currents in phi-
displaced. When the mind is further equated with losophy which were emerging from the nineteenth
the brain, the issue of responsibility is dissolved century. Those who take an anti-positivist position
altogether. argue, in opposition to positivism,1 that the con-
For Szasz, as for Wittgenstein, therefore, our cepts and methods we use to investigate the natural
language of mental states and emotions signifies world in a scientific manner are fundamentally dif-
attributes of whole living persons who are actively ferent from the ways in which it is appropriate and
engaged in the social and material world. Our meaningful to understand human behavior, and
the mental attributes that it manifests. Scientific
Moncrieff / Szasz and Wittgenstein on the Nature of Mental Disorder ■ 5

methods and theories are premised on the predict- These philosophers do, however, identify the
ability of the physical environment, which in turn important point that we want to use the term
derives from the fact that non-living things do not ‘disease’ to describe a characteristic situation that
have volitional agency. Unlike inanimate matter, is associated with the material world and is ame-
living organisms behave in ‘purposeful’ ways, to nable to scientific description and investigation. In
maximize their chances of survival and reproduc- this sense they accept Szasz’s position that there
tion (Hacker, 2010). Higher animal life has the is a distinction between disease and situations
capacity to respond flexibly to the environment characterized by problematic behavior. However,
through self-directed action. Human beings, more- their aim is to incorporate mental disorders into
over, have the capacity for ‘reason,’ that is, they the concept of disease to establish them firmly
can reflect on and weigh up the options available within the realm of medicine and science, and to
to them. Unlike the subject matter of the physical refute the Szaszian claim that they belong in the
sciences, therefore, people have motives, interests world of behavior.
and purposes, they make choices and do things for
reasons. Although human actions are, of course, Distinguishing Disease and
influenced and constrained by various factors in- Behavior
cluding human biology and the current and past
circumstances of each individual’s life, they are not In contrast, and in line with the anti-positivist posi-
determined. They cannot simply be understood as tion, Szasz understands that mental processes, in-
the inevitable product of a given set of conditions. cluding those that occur in the context of what we
It is argued, therefore, that understanding human call a mental disorder, are inextricably linked with
behavior is logically different from the way we behavior, and that behavior, as it normally occurs,
understand the material world (Winch, 2008). is categorically different from a biological state
In particular, knowledge about human activity such as a disease. As part of the material world,
does not result in universally applicable laws or bodily processes are biologically programed in
principles, and it cannot be ‘objective’ in the way ways over which human beings have limited con-
that our knowledge of the material world strives to trol. Our bodies grow and develop in characteristic
be because the researcher can never stand outside ways following general laws of human biology and
the world she is researching. There is no neutral development. Similarly, cancer cells multiply and
point of view. Wittgenstein’s particular contribu- disseminate in a predictable fashion that is a con-
tion to this debate is his demonstration that ‘the sequence of the inherent nature of cells in general
mind,’ or the mental, since it is indissolubly linked and cancer cells in particular. We can influence our
with human behavior, cannot be grouped in with bodies by acting on them. We can develop muscle
the material world and investigated using the mass by exercising, increase or decrease our weight
approach of natural science. Our psychological through modifying our diet, for example. We can
attributes are human affairs, not ‘natural’ ones. sometimes modify a disease process, too, by acting
This analysis shows how the arguments of the on our bodies through physical means like taking
‘naturalists,’ such as Boorse (1976) and Wakefield drugs, going on a diet or making ourselves relax
(1992), who regard mental functions as analogous to reduce pain or wheezing. Nevertheless, just as
to biological functions, are misguided. The idea we are subject to the inexorable logic of biologi-
that dysfunctional psychological processes that cal aging, we cannot rid ourselves of cancer just
can be understood in the same way as dysfunc- because we wish to (or so most people believe
tional biological processes is to misunderstand and science indicates). We cannot modify arthritis
the nature of mental states and events. It fails to by an act of will alone. Biological processes are
appreciate the link between mental attributes and governed by predictable regularities which, like
the behavior in which they are manifested, and the chemical reactions, have nothing to do with the
way that this behavior derives its meaning from desires and purposes of individual human beings.
the social world in which it is embedded. Thus, we can apply a scientific framework to
6 ■ PPP / Vol. 27, No. 2 / June 2020

biological matter, one that is based on identifying physiological or neurochemical alterations, but
and characterizing universal laws based on causal ordinary behavior is not properly thought of as
relationships between entities and events. a casual consequence of such alterations (unless
We have already seen that a disease of the brain you are a eliminativist or neurodeterminist, like
or another part of the body can cause certain be- Churchland, who wants to redescribe all human
haviors or activity, such that it makes sense to say activity in terms of neural events, a position that
that the result is attributable to the disease, rather has been rebutted by numerous thinkers2).
than the individual’s agency. An epileptic fit, for Churchland’s example of the brain tumor il-
example, is the result of anomalous electrical activ- lustrates how it is evident that in real life we do,
ity in the brain. It does not count as ‘behavior’ as as Szasz suggests, find it important to distinguish
we ordinarily know it. Similarly, the brain tumor situations that arise as a consequence of a bodily
in Churchland’s example directly influenced the state or event, and those that consist of ordinary
behavior of the sufferer, producing actions that human behavior, that is activity initiated by an
were ‘out of character.’ Brain diseases like demen- autonomous, self-directing individual. The dis-
tia and advanced multiple sclerosis also commonly tinction between epileptic fits and contrived fits
produce more or less subtle changes in a person’s provides another example. We think of someone
behavior. The bodily conditions that give rise to as having the disease of epilepsy when we have
these situations are biological entities or processes reason to believe that the ‘fits’ they show are due to
that are part of the natural world. Therefore, it is abnormal electrical impulses in the brain. But we
appropriate to describe them in terms of biological know that sometimes people imitate epileptic fits
science, and to investigate their nature and origins for various reasons. In medicine, these situations
using scientific methods, just as we can look for are distinguished from actual epilepsy by refer-
the bodily origins and mechanisms of pain. We ring to them as ‘pseudo-seizures’ or ‘functional’
can meaningfully speak in terms of the biologi- seizures.
cal processes ‘causing’ characteristic ‘behaviors’ We treat people who imitate fits, whether they
(which we then refer to as symptoms), in the sense do so consciously or unconsciously, differently
that the latter are a predictable consequence of the from people whose fits originate from abnormal
former. Identifying the specific abnormalities that brain currents. Working in a drug detoxification
constitute the disease can lead to the development unit making the distinction is an everyday chal-
of medical ‘treatment’ which will be designed, lenge. People who have been using large amounts
ideally, to act on the abnormal anatomical, bio- of alcohol or benzodiazepine drugs are liable to
chemical or physiological pathways at some level. have epileptic fits during detoxification, which can
For Szasz, only ‘behavior’ that is directly driven be life threatening and need immediate treatment
by a biological process in this way can be deemed with anti-epileptic agents. People with a history
to be an illness or disease, or the symptoms of such. of addiction may also fake fits, however, to obtain
Szasz illustrates the importance of the distinction these substances. If you give people who fake fits
between bodily events and ordinary behavior by anti-epileptic drugs, you not only expose them
highlighting how we distinguish an intentional ac- to unnecessary harm, you also undermine the
tion like a wink, which has meaning and purpose, principles of the recovery program for everyone
from an involuntary muscle spasm such as a blink involved.
or twitch of the eye, even though the actual move- Such situations illustrate the problem with
ment may be the same in both cases (Szasz, 1996, views that try to uncouple disease or illness con-
p. 24). We can also think of the difference between cepts from the body. Thinkers such as Bill Fulford
a deliberate kick and a muscle spasm. Behavior and Peter Sedgwick, for example, suggest that
that is not the direct result of a biological process, what is fundamental to these concepts is that they
is, by definition, the expression of an autonomous signify situations that are unwanted, because they
human being, a manifestation of human agency. cause pain or discomfort, or because they prevent
This not to suggest that behavior does not involve us doing what we want to be doing (referred to as
Moncrieff / Szasz and Wittgenstein on the Nature of Mental Disorder ■ 7

‘action failure’ by Fulford) (Fulford, 1989; Sedg- calized aspects of ordinary life, are ‘as yet to be
wick, 1982). In other words, they are evaluative discovered’ brain diseases (Craddock et al., 2008).
terms. Therefore, they argue, unwanted mental Although this position is logically consistent with
states or disorders can also qualify as disease or the critique expressed above, it seems unlikely
illness. As Wittgenstein illustrates, however, we that it will ever account for most instances of
cannot hive off the psychological from the realm what we currently refer to as mental disorder. It
of human social behavior, and eliding mental and is sometimes claimed, for example, that mental
physical illness on the basis that both sorts of con- disorders like schizophrenia or depression have,
ditions cause suffering, discomfort or functional in fact, already been demonstrated to be brain
failure implies there is no value in distinguishing diseases (Insel & Cuthbert, 2015). However, the
between an unwanted condition of the body, and evidence is far from conclusive. The most consis-
other unwanted situations that involve various tent finding in schizophrenia is its association with
sorts of human behavior. Yet this is clearly not reduced brain volume, but the confounding effects
true. Cancer and burglary are both negatively of intelligence have never been properly addressed,
valued situations but that does not make them the and recent research confirms that the association
same sort of thing! is, at least in part, a consequence of antipsychotic
Szasz did not deny, as is sometimes implied, that drug treatments (see Moncrieff & Middleton
the concepts of disease and illness are evaluative [2015] for a review of this literature). The idea
concepts. He did not view a biological deviation that schizophrenia or psychosis is a consequence
as sufficient to define something as a disease in the of abnormal dopamine levels is also not consis-
absence of undesired consequences. A biological tently supported and there is much contradictory
notion of disease still incorporates value judgments evidence (Kendler & Schaffner, 2011; Moncrieff,
about what sorts of bodily states or attributes are 2009). Similarly, the widely promoted theory that
‘normal’ or desirable. Szasz merely observed that depression is a consequence of abnormal serotonin
wanted or unwanted, bodily conditions can be levels or activity has also never been convincingly
described in terms of biology: ‘although the de- demonstrated (Healy, 2015). Moreover, as Szasz
sirability of physical health, as such, is an ethical pointed out many times, if we did discover that
norm, what health is can be stated in anatomical a particular disorder, or some cases of it, were
and physiological terms’ (Szasz, 1989, p. 14). If caused by a specific neurological abnormality we
you loosen the association between the concepts would reconceptualize the situation. We would
of ‘illness’ and ‘disease’ and the body, you empty redesignate the problem either as a fully fledged
them of their distinctive meaning. They are no neurological condition that then comes within
longer able to pick out a particular category of the domain of neurology, as occurred with neuro-
unwanted situations and they become synonymous syphilis, or we would, at least, distinguish it from
with generic terms like ‘problem’ or ‘difficulty.’ We ‘run of the mill’ mental disorders by referring to
can no longer distinguish between the man with it as an ‘organic,’ or, in more recent terminology
the brain tumor and the ordinary sex offender in as a ‘neuropsychiatric’ condition, like dementia.
terms of our moral evaluation or our practical Although it can be argued that strong evidence
response. Divorced from the body, ‘disease’ and for a biological causation may yet become ap-
‘illness’ cease to have any discriminative power. parent for some situations currently identified as
They become meaningless. ‘mental disorder,’ it seems right to assume that
behavior is autonomous, unless proven otherwise,
Mental Disorder as Brain just as it is generally agreed that capacity should
Disease be presumed unless or until there is good evidence
to the contrary.
Several leading psychiatrists agree with Szasz in A popular view on the nature of mental disor-
the sense that they maintain that ‘real’ psychiatric ders, sometimes referred to as the ‘biopsychoso-
conditions, as opposed to inappropriately medi- cial’ model, suggests that biological factors may
8 ■ PPP / Vol. 27, No. 2 / June 2020

have a partial role in the causation of mentally Wittgenstein goes on to illustrate the conceptual
disordered behavior and experiences. Yet, it is not similarity between the symptoms of madness and
clear what it would mean for a physical process to more familiar feelings and behaviors:
be partially causative of behavior. In particular, it Everybody is (or most are) mistrustful, and
is not clear how biological causation is compat- perhaps more so towards their relations than
ible with agency. If we understand a ‘behavior’ towards others. Is there any reason for mistrust?
as being the direct result of a biological process, Yes and no. Reasons can be given for it but they
this takes it out of the realm of agency—as in the are not compelling. Why shouldn’t somebody
case of a blink or an epileptic fit. Biological cau- become much more distrustful of other people?
Why not much more withdrawn? Or devoid of
sation trumps other explanations of behavior. As
love? Don’t people get like this even in the or-
described above, this is not to deny that biology is dinary course of events? Where is the line to be
involved in ordinary behavior too. Our characters drawn here between will and ability? Is it that I
are the result of complex interactions between our will not open my heart to anyone any longer, or
biology and our individual interests and desires as that I cannot? If so much can lose its attraction,
they have co-evolved through the course of our why not everything? If someone is wary even in
lives. Moreover, biological events co-occur with all ordinary life, why shouldn’t he—and perhaps
autonomous behavior, thoughts and feelings. We suddenly—become much more wary? And much
more inaccessible? (Wittgenstein, 1970, p. 62)
are a long way from being able to match specific
biological states with any particular behaviors or The suggestion that rather than the eruption of
mental events or states that are not symptoms of a diseased brain, madness should be understood
an established brain disease, however. Even if we as a complicated, and possibly confused but self-
could, this is not the same as identifying a biologi- directed reaction to the world is reminiscent of
cal cause or instigator of that behavior. other attempts to explore the meaning of mad-
ness. The leading American psychiatrist of the
Mental Disorder as Behavior mid-twentieth century, Adolf Meyer, proposed
or Character that ‘mental illness’ consisted of people’s attempts
to manage circumstances they found to be chal-
If it is not the result of a neurological or bodily lenging or uncomfortable. It was, he described, ‘a
disease, then, as Szasz claimed, the behavior that genuine but faulty attempt to meet situations, an
we classify as mental disorder is just that, a form attempt worthy of being analyzed’ (Meyer, 1948,
of behavior. Wittgenstein also suggested this in a p. 136). A behavioral ‘symptom,’ such as social
passage in Culture and Value that is cited by Szasz withdrawal, for example, can be understood as an
(Szasz, 1990; Wittgenstein, 1970). Wittgenstein attempt to resolve or avoid a personal dilemma,
starts by suggesting, “Madness doesn’t have to be but one that soon becomes a problem in its own
regarded as an illness. Why not a sudden—more right. This is similar to R.D. Laing’s views of
or less—change of character?” (Wittgenstein, psychosis as a retreat into an internal world that
1970, p. 62). is motivated initially by the desire to avoid what
Wittgenstein’s contrast of illness and charac- is, for some, the intolerable anxiety of modern
ter is consistent with Szasz’s distinction between adulthood (Laing, 1965).
conditions that originate in the body and those Some of the behaviors and utterances we associ-
that are constituted by ordinary human behavior, ate with mental disorder are not straightforwardly
and the thoughts and emotions that are expressed meaningful or what we would generally accept as
therein. Since the way we behave reflects what is rational, however. They do not have a purpose that
seen as our character, madness can be seen as an is readily apparent to other people, and sometimes
aspect of character, although sometimes one that, reasoning processes seem to be awry, or at least
somewhat unusually, only emerges from time to quite different from those of ordinary life. People
time. with delusions, for example, can form beliefs on
the basis of illogical and unlikely connections
Moncrieff / Szasz and Wittgenstein on the Nature of Mental Disorder ■ 9

between events, and are usually not amenable to The issue of agency in relation to mental disor-
counterarguments or evidence. They seem to have der is highly complex, and Wittgenstein highlights
stepped outside the shared assumptions about the the thin ‘line ….between will and ability.’ The
world that make normal social interactions pos- preceding points suggest that regarding mentally
sible. Indeed, ethnomethodologist Jeff Coulter disordered behavior as a part of the self or charac-
(1979), who was much influenced by Wittgenstein, ter, as opposed to an illness or disease that is quite
argues that ‘mental illness’ is attributed when separate from it, does not necessarily entail that
someone acts in a way that is not easily intelligible, the individual should be regarded as fully respon-
and breaks the unwritten rules of social conduct sible for all of their actions. Most philosophical
that express our shared rationality. The commu- commentators believe that in some circumstances,
nity identifies someone as being mentally ill when at least, people with mental disorders are not fully
they behave unpredictably, for example, or fail autonomous, and therefore cannot be held respon-
to meet basic social expectations like engaging in sible for certain behaviors (Broome, Bortolotti, &
comprehensible conversation or activity. Mameli, 2010; King & May, 2018). Generally, in
Moreover, in some instances the behavior we legal situations and ordinary life, we do not hold
refer to as mental illness may not have any discern- people responsible if they appear to be unable to
ible meaning or purpose. An episode of extreme make reasoned choices about what they do based
over-arousal, such as we might call mania, or on shared principles of rational thought. Szasz,
less commonly a period of depression, may just however, argues that psychotic phenomena like
occur for no reason, in the same way that not delusions and hallucinations, although irrational,
all our daily moods can easily be explained by may be understood as being purposeful, and, be-
recent events or circumstances. Hacker highlights cause they emanate from the individual, should
how moods and emotions are not instigated by be regarded as under their control (Szasz, 1996).
us voluntarily, but nevertheless form part of our Along with other thinkers like Laing and Meyer,
character. This is partly because they are intimately therefore, he seems to be suggesting that people
connected with our beliefs, opinions and judg- may, at times, choose to adopt irrational ways of
ments, but also because the way we express our thinking and behaving. However, although in some
emotions is part of what is characteristic about places Szasz draws the conclusion that people with
us as individuals. Yet the behavioral expressions mental disorders are ‘always responsible for their
of our emotions are not always fully intentional conduct’ (Szasz, 1989, p. 135), at other points he
and sometimes not entirely under our control. hints that people may sometimes be considered
Our emotional behavior can be understood as on to be ‘incompetent’ by virtue of their mental state
a ‘spectrum’ from the consciously or unconsciously (Szasz, 1998). He stresses, though, that ‘incompe-
intentional (smiling when greeting a friend) to the tence’ is a legal category and should be determined
involuntary (yawning with boredom). Usually, we judicially and not medically. Hence, it seems that
are able to exert some degree of control over how Szasz agrees that there are times when agency and
we respond to our feelings, and sometimes we responsibility may be compromised in the absence
might actively resist the feeling itself, when it is of a physical disease.
anger or jealousy, for example, with more or less Overall, therefore, the constituents of madness
success. Yet sometimes we are not able to suppress or ‘mental illness,’ are not fundamentally different
a smile or a laugh when we know we ought to. from other human behavior and experience, and
Similarly, although not the same situation as an therefore can be viewed as an aspect of a person’s
involuntary movement or response (like a spasm), character. What we call mental symptoms arise
someone in the midst of a serious episode of mental from the self; often, though not necessarily always,
disorder does not seem to be in full control of their as a reaction to external events, in the same way
behavior. It seems likely that they are not always that more ordinary fears, preoccupations and com-
able to make reasoned choices about what they pulsions arise. In this sense they are expressions
do, or to decide to act otherwise. of the individual’s existence, as R.D. Laing put it
10 ■ PPP / Vol. 27, No. 2 / June 2020

(1965). The behaviors and experiences associated who sometimes acts in an anti-social way, but
with mental illness are distinctive in a number of just a walking expression of his brain processes.
ways, however, particularly because they are some- 1therefore, it is legitimate to ignore his wishes and
times not fully rational or controllable. Sometimes chemically eliminate or suppress the inconvenient
‘mentally ill’ behavior breaks the shared assump- behavior. This is the implicit basis of modern
tions that enable us to understand and relate to mental health legislation that enables people like
each other; its rationale and motivation are not Eric to be forcibly confined and medicated on the
transparent. Nevertheless, the behaviors we call basis that they have a mental disorder.
mental disorder are part of the range of ways in If, on the other hand, Eric’s behavior is seen as
which human beings live within, and interact with, an expression of his individuality, as an integral
their world. part of his character, and not as a disease or sick-
ness, then addressing the situation is complex and
Implications more difficult to justify. Outside of the current,
mental health system, he could be prosecuted for
In a world that prizes individual liberty and au- causing a disturbance to his neighbors, but he
tonomy, deeming mental disorder to be, or to be would receive a modest penalty and it is unlikely it
like, a disease facilitates certain social mechanisms would make a difference to his behavior. He could
for addressing the problems it can pose. Szasz be evicted, but then the same problem would occur
argues that the medicalization of certain challeng- elsewhere. Attempts could be made to persuade
ing behaviors is a strategic maneuver that modern him to change his behavior through therapy, but
societies make to justify a system of social control it is difficult to sustain a conversation with him,
and welfare that would otherwise be highly con- let alone to conduct therapy. It is probable that
tentious (Szasz, 1970). David Ingelby (1982), too, he would quickly become homeless and destitute,
shows how presenting certain social arrangements because he would not qualify for sickness or dis-
as medical treatments for medical conditions con- ability benefits, and his behavior is incompatible
fers legitimacy they would otherwise lack. Aban- with finding or maintaining employment.
doning the ‘medical model’ of mental disturbance, It seems, therefore, that if we reject the notion
therefore, presents considerable challenges to the that mental disorder is a disease, we still need
legality and acceptability of the modern system a mechanism that recognizes and addresses the
of mental health care, and raises questions about difficulties that ‘mental disorders’ can represent
how else we might respond to the problems we for individuals and others around them. We need
call mental disorder. a system that can balance the need to restrict
Consider the case of Eric, a fictional patient people’s behavior when it becomes a nuisance
who presents some of the typical issues encoun- or danger to other people, with the individual’s
tered in modern services: Eric is a middle-aged legitimate interests to live in the way they want to
man who lives in a block of flats where he is sur- live. We also need a way to fairly and transparently
rounded by other people, including elderly people distribute resources and care to people who are
and families with young children. He periodically unable to be financially or practically independent,
shouts throughout the night—he says he is pray- without having to deem them as sick.
ing—which disturbs his neighbors, and from time Such a system would require a different basis
to time he thinks they are conspiring against him, for decisions about depriving someone of their
and starts threatening them. Taking antipsychotic liberty, or forcing them to ingest drugs they do
medication seems to reduce his paranoid thinking not want to take. Without the justification of
and makes his behavior more socially acceptable, treating a medical disease, such decisions would
but he dislikes it intensely and he does not recog- need to involve an explicit process of balancing
nize that there is anything wrong with his behavior. the interests of different parties, and would have
If Eric’s behavior is regarded as the manifes- to be subject to greater scrutiny and democratic
tation of a brain disease, it does not need to be control than at present. Currently, the notion that
taken seriously. He is not an eccentric character,
Moncrieff / Szasz and Wittgenstein on the Nature of Mental Disorder ■ 11

mental disorder is a medical condition and that interpersonal issues, people who fully absorb the
intervention means ‘treatment,’ means there is disease model will realize that it leaves no room
an inherent bias towards assuming intervention for depression to have meaning, and such people
will be helpful and benign. It is also not obvious wait for antidepressants to ‘work,’ while some-
that the medical profession should have a central times enduring circumstances that would make
role, although medical expertise for the exclusion anyone depressed! In this way, the disease concept
of physical conditions and safe and rational use of depression may trap people in a disabling view
of drugs would still be important. There may be that they are fundamentally biologically flawed,
pragmatic advantages to locating a new system with little they can do to help themselves.
within the medical system—that is within the If ‘depression’ is thought of as the emotional
existing psychiatric system or something resem- response of a whole human being, on the other
bling it—such as retaining the prestige and fund- hand, then it cannot be properly understood with-
ing that accompanies medical activity. However, out identifying the context or circumstances that
the dangers of this would be that proper scrutiny it is a response to, and thinking about the nature
of decisions and balancing of different interests of the behavior in which it is manifested. The idea
would not be achieved because a medicalized that we can exert some control over our moods,
understanding would remain prevalent. emotions and behavior encourages people to find
Our current mental health system has extended ways to change or manage these. For many, this
far beyond the remit of any system of social con- is fundamental to achieving recovery (Conneely,
trol, however. Professionals and members of the Higgs, & Moncrieff, 2019).
public alike have welcomed the medicalization of
more familiar forms of distress, such as those we Conclusions
refer to as anxiety and depression. Highlighting
again the importance that is attributed to distin- As these examples illustrate, regarding a situation
guishing disease from behavior, official informa- as a disease or illness has important consequences
tion and education about depression emphasizes that flow from the association of these concepts
that it is ‘a real illness. It is not a sign of a person’s with biological or bodily conditions. Whether
weakness or a character flaw’ (National Institute mental disorders rightly quality as diseases or
of Mental Health, 2018). The idea that depression whether they should be understood as patterns of
is a disease, which can be described in biological unwanted behavior, as suggested by Thomas Szasz,
terms and hence has nothing to do with the indi- is, therefore, a critical question. Wittgenstein’s
vidual’s real self, is contrasted with the idea that philosophy illustrates that the ‘mental’ cannot
it reflects the person’s character and is, therefore, be equated with the biological, as some philoso-
liable to moral judgment. phers have tried to do, since mental attributes are
We can appreciate the appeal of embracing inherently entwined with public behavior. In the
the idea that depression is a disease in terms of absence of evidence for a bona fide brain disease,
deflecting blame and responsibility, especially if therefore, what we characterize as mental illness
it is linked with the idea that there is a simple, or disorder refers to patterns of unusual, but
physical remedy, such as an antidepressant. Yet the still essentially self-directed behavior that can, as
separation of the ‘depression’ from the individual Wittgenstein suggested, be understood as aspects
has other consequences that are not necessarily of character. Such situations have a complex rela-
helpful. The depression-as-a-disease approach tion to agency, however, because the characteristic
plays down the role of context or circumstances experience and behaviors are not always rational
by locating the problem in the individual’s biology, or fully controllable.
and logically implies that the individual cannot Due to their implicit association with the body,
change their situation except by changing their aligning our understanding of mental disturbance
brain. Although all good professionals try and with concepts of disease and illness enables vari-
help people to identify and address social and ous social functions, including the operation of
12 ■ PPP / Vol. 27, No. 2 / June 2020

social control and welfare systems. The idea that Conneely, M., Higgs, P., & Moncrieff, J. (2019).
mental conditions are a disease is more widely Medicalising the moral: The case of depression as
popular because of the exemption from moral revealed in internet blogs. Social Theory and Health.
Unpublished manuscript submitted for publication.
judgment that it seems to entail. Accepting the
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Acknowledgments Hacker, P. M. (2004). The conceptual framework for
The author thanks Professor Peter Hacker for the investigation of emotions. International Review
of Psychiatry, 16 (3), 199-208.
helpful suggestions on a draft of this article, Steven
Hacker, P. M. S. (1997). Wittgenstein. London: Phoenix.
Tresker for useful discussion on the philosophy of Hacker, P. M. S. (2010). Human nature: The categorical
disease, and to the organizing committee of the framework. Oxford: Wiley-Blackwell.
Association for the Advancement of Philosophy Hartner, D. F., & Theurer, K. L. (2018). Psychiatry
and Psychiatry for giving me the opportunity to should not seek mechanisms of disorder. Journal of
collect my thoughts on this subject at the 2017 Theoretical and Philosophical Psychology, 38 (4),
annual conference. 189-204.
Healy, D. (2015). Serotonin and depression. BMJ, 350,
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