Moncrieff’s views on the nature of mental illness: the false binary between disease and behavior

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This post is a way for me to reflect on Joanna Moncrieff’s article “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 Disorder" published in Philosophy, Psychiatry, & Psychology.

I find myself in substantial disagreement with the assumptions and conclusions of Moncrieff’s article, so in this post I will try to unpack some major points of contention. An abbreviated version of this post will later be submitted to the journal as a formal commentary.

In section 1 I focus on the major points of my commentary.
In section 2, I elaborate some of the arguments made earlier, and also address some minor points.

In all sections and sub-sections, I quote liberally from the original article so that readers can contextualize the arguments being made. 

Section 1

The distinction between bodily processes (diseases) and self-directed behavior

• “… the distinction between bodily conditions, such as diseases, which may affect behavior, and situations that comprise self-directed behavior. This distinction was emphasized by the late Thomas Szasz, who recognized that regarding a situation as a disease or illness has important consequences that flow from the association of these concepts with the body.” 
• “Whether mental disorders rightly qualify as diseases or whether they should be understood as patterns of unwanted behavior, as suggested by Thomas Szasz, is therefore, a critical question.”

This distinction is a typical example of a false binary (or the logical fallacy of the excluded middle). False binaries distill a complex set of options into two mutually exclusive options. Moncrieff, following Szasz, categorizes behaviors as either resulting from a bodily process or as self-directed behavior. First, the two options are not mutually exclusive. There is a complex relationship between self-directed behaviors and underlying biological processes, which can include diseases. Second, many psychological states and psychiatric conditions cannot be adequately described using the terms “self-directed” and “behavior”. Consider a state of low mood. Low mood may manifest in observable behavior but not necessarily so, so behavior cannot be considered a satisfactory descriptor. Mood states also cannot be described as “self-directed” since they are not under voluntary control. Experiencing auditory hallucinations falls neither under “behavior” nor under “self-directed”. This mischaracterization of complex psychological states and psychiatric conditions as “self-directed behaviors” creates a lot of confusion and in my opinion leads Moncrieff to arrive at invalid conclusions.

The ‘mental’ and the ‘biological’

• “Both Szasz and Wittgenstein suggest that we misunderstand the nature of ‘mind,’ and that mental states and events are not independent entities that can be discovered and described by natural science, but activities of living human beings that are manifested in, and recognized through, forms of public behavior.” 
• “Wittgenstein’s philosophy illustrates that the ‘mental’ cannot be equated with the biological, as some philosophers have tried to do, since mental attributes are inherently entwined with public behavior.”

Whether the entire realm of psychological phenomena can be understood as “activities of living human beings” that manifest in “forms of public behavior” is certainly a controversial notion. I disagree with it, but I don’t think it’s really necessary to debate this particular philosophical assertion. The more pertinent point is that the mental cannot be equated with the biological. I agree that mental cannot be equated with the biological, however, that nonetheless leaves open a myriad of ways in which the biological relates to the mental. This applies not just to psychiatric conditions but also to “normal” and “ordinary” experiences. Consider sexual desire. Sexual desire is certainly a “mental” phenomenon. We are consciously aware of it. Sexual desire is psychologically meaningful, and it is usually directed at a particular object. While sexual desire is “mental”, it is influenced by biological factors such as the production of various hormones. Sexual desire cannot be “equated with” hormonal signaling, but hormonal signaling plays an important role, and changes in hormonal signaling underlie as well as influence the experience of sexual desire. Going back to the earlier point regarding ‘self-directed behavior’, while sexual behavior can be self-directed, it makes little sense to describe sexual desire as self-directed. We do not choose to experience sexual desire, we can exert some control over it but it is not entirely under our control, and we have little control over the object of our desires.

Mental Disorders and Biological Processes

• “Mental disorders, which are also manifested in behavior, cannot, therefore, be aligned with biological conditions, unless there is evidence of an underlying disease.” 
• “In the absence of evidence for a bona fide brain disease, therefore, what we characterize as mental illness or disorder refers to patterns of unusual, but still essentially self-directed behavior that can, as Wittgenstein suggested, be understood as aspects of character.”

Since the two preceding assumptions are false, this conclusion is false as well. Mental disorders can very well have substantial biological underpinnings, and many mental disorders can neither be characterized as “self-directed behavior” nor as “aspects of character”.

Self-Directed Behaviors and Agency

Moncrieff sees mental disorders as aspects of character and self-directed behaviors, but she acknowledges that they are not always rational or fully controllable, and for that reason they may not necessarily be accompanied by moral responsibility. 

• “These patterns can be understood as aspects of character, although they have a complex relationship to agency.” 
• “Such situations have a complex relation to agency, however, because the characteristic experience and behaviors are not always rational or fully controllable.”
• “regarding mentally disordered behavior as a part of the self or character, as opposed to an illness or disease that is quite separate from it, does not necessarily entail that the individual should be regarded as fully responsible for all of their actions.”

Stating that “self-directed behaviors” are “not always fully controllable” and may not be associated with moral responsibility seems to me to be a contradictory effort, especially since one of the reasons Moncrieff is against viewing mental disorders as diseases is because it contradicts the sense of agency. It is also odd that Moncrieff allows “aspects of character” to be have a complex relationship with agency, yet she denies the same complex relationship to behaviors caused by disease processes such as brain tumor. I would argue that the relationship between behaviors and brain tumors can be just as complex.

***

Section 2

Behaviors Directly Caused by Biological Processes

• “If we understand a ‘behavior’ as being the direct result of a biological process, this takes it out of the realm of agency—as in the case of a blink or an epileptic fit. Biological causation trumps other explanations of behavior.”

• “a disease of the brain or another part of the body can cause certain behaviors or activity, such that it makes sense to say that the result is attributable to the disease, rather than the individual’s agency. An epileptic fit, for example, is the result of anomalous electrical activity in the brain. It does not count as ‘behavior’ as we ordinarily know it. Similarly, the brain tumor in Churchland’s example directly influenced the behavior of the sufferer, producing actions that were ‘out of character.’”

It is a mistake to lump an “epileptic fit” with complex behavior such as pedophilia arising in the context of a brain tumor. An epileptic fit by-passes the conscious decision-making processes of our mind-brain. Neurological reflexes such as a blink also involves no conscious decision-making. Pedophilic behavior, however, is much more complicated because it does involve conscious awareness and decision-making.

What does it mean for complex human behavior – characterized by awareness, intention, and conscious decision – to be caused by a brain tumor? How exactly does a brain tumor result in pedophilic behavior? It doesn’t cause it in the same manner as a neurological reflex. It doesn’t turn the person into an automaton. Instead, what it does is that the tumor – due to the involvement of relevant biological processes – influences the desires experienced by the person. The object of sexual desire shifts, the severity of sexual desire increases, and at the same time the influence of conscious ability to inhibit and suppress urges is lowered. With or without disease processes, our desires and our inhibitions are modulated in part by neurological mechanisms.

Some individuals may by default have functional configurations of neurological mechanisms that lead sexual desire to be focused on pre-pubescent children. From Moncrieff’s perspective, this is simply “an ordinary criminal case of pedophilia”. From her perspective, people with pedophilic desire demonstrate “self-directed behavior” and as having a certain sort of “character”, and should be liable to moral judgment, but if the pedophilic desires are a result of a brain tumor, then this “ceases to have the characteristics of ordinary behavior and can sensibly be described as ‘symptoms’ of a disease.”

Individuals with “pedophilic disorder” have recurrent, intense sexually arousing fantasies or sexual urges involving sexual activity with a prepubescent child on a sustained, possibly life-long basis. Like everyone else, they do not choose the object of their sexual desire. Often, they find it distressing, horrifying and repulsive. What is the difference between pedophilic disorder and pedophilic sexual urges in the context of a brain tumor? The main difference is that the causal explanatory power for the presence for pedophilic urges in the case of a brain tumor is concentrated in the focal process of a brain tumor while the causal explanatory power for pedophilic disorder is more diffuse, and spread out over genetic, hormonal, neurobiological, and psychological factors. The focal concentration of explanatory power in the case of a brain tumor makes it possible to address it more effectively (for instance with surgery), while the diffuse nature of causality of pedophilic disorder makes effective intervention more difficult. Both of them, however, have a complex relationship with agency and moral responsibility. 

Biology as “Partially Causative” of Behavior

• Moncrieff writes: “it is not clear what it would mean for a physical process to be partially causative of behavior. In particular, it is not clear how biological causation is compatible with agency. If we understand a ‘behavior’ as being the direct result of a biological process, this takes it out of the realm of agency – as in the case of a blink or an epileptic fit.”

From a scientific perspective which assumes physical determinism, “autonomous behavior” is considered autonomous not because it is the result of some metaphysical free will, but rather because the behavior springs from an individual’s intentions, thoughts, desires, and conscious decisions. However, these intentions, thoughts, desires, and decisions themselves do not arise in the mind-brain ex nihilo. They arise from the apparatus of the mind-brain and they are subject to a variety of biological influences. Whether these influences should be considered a “cause” is a semantic argument, but these influences on autonomous behavior are a scientific reality.

Consider sexual desire… different individuals have different baseline levels of sexual desire and different objects of sexual desire. This is not the result of a voluntary, autonomous choice. It is regulated in part by hormonal and neurological mechanisms, and it is a legitimate scientific question to ask whether differences in hormonal and neurological mechanisms account for some of the variation in the sexual desire experienced by individuals.

Attribution of Mental Illness

As Moncrieff acknowledges, 
‘mental illness’ is attributed when someone acts in a way that is not easily intelligible, and breaks the unwritten rules of social conduct that express our shared rationality. 

And when that happens, when we experience desires, thoughts, moods that seem to violate our expectations and cause impairment or distress, or when the behavior is not intelligible and rational, it is a fair question to ask: how do these desires/thoughts/moods/behaviors differ from desires/thoughts/moods/behaviors that don’t violate our expectations and don’t cause impairment or distress. Sometimes the answer is found entirely within the realm of psychological understanding, but at other times the answer may be more complex with influences that are best approached employing many different levels of explanations, including biological.

Agency and Moral Responsibility

• “regarding mentally disordered behavior as a part of the self or character, as opposed to an illness or disease that is quite separate from it, does not necessarily entail that the individual should be regarded as fully responsible for all of their actions.”

This, however, contradicts Moncrieff’s efforts to assert “agency” in mental disorders by taking them out of the realm of “disease”. She writes, “it is not clear how biological causation in compatible with agency. If we understand a ‘behavior’ as being the direct result of a biological process, this takes it out of the realm of agency”… but acknowledging that someone shouldn’t be regarded as morally responsibly for their action is another way of saying that their agency is compromised. Notions of agency and moral responsibility go hand in hand. It makes little sense to argue that an individual has agency but has no moral responsibility.

Understanding the Material World vs Human Behavior

• “philosophers who take an ‘anti-positivist’ position have long suggested that it is important to distinguish how we understand the material world, which includes autonomous biological processes like diseases, from our understanding of human behavior”

There are also philosophers like Karl Jaspers who have argued that ‘understanding’ (meaningful and comprehensible connections that are inherent in one’s personality and biography) and ‘causal explanation’ (causal connections that are mainly rooted in biology) are not mutually exclusive, but rather both perspectives can be applied to our psychological lives and the two perspectives are complementary and necessary, generating a need for “pluralism” of perspectives.

• “Unlike the subject matter of the physical sciences, therefore, people have motives, interests and purposes, they make choices and do things for reasons.”

All of that is still applicable to the individual with pedophilic behavior and brain tumor. The brain tumor makes an impact via the motives, interests, choices and reasons of the individual. Yet Moncrieff has no problem understanding this in the manner that we understand the material world.

Arbitrary Exclusions from the ‘Mental’: The Example of Pain

• “Wittgenstein famously gives the example of pain and shows that we learn how to use the term ‘pain’ to describe our own experiences through learning how the term is applied to situations in which other people are said to be in pain. The first person and third person use are indissolubly linked, and the first person use to describe a personal experience is only logically possible given mastery of the third person use, which is based on behavioral grounds or criteria”

Despite quoting this example from Wittgenstein, Moncrieff’s view of pain subsequently in the article seems to be very different; instead of a mental state with all the complexity of first-person-third-person-indissoluble-link, pain suddenly becomes a “physical sensation” or a “physiological state”: Moncrieff writes, “In other words, unlike physical sensations or physiological states, such as hunger or pain, emotions and moods, like thoughts and behavior, are usually meaningful”.

This arbitrary decision to cut off “pain” from the mental life is made without any philosophical justification. If “pain” can be understood as both a complex meaning-ladden mental state and a physiological state, then there is no reason why other mental phenomena such as emotions cannot be.

Manifestations of Human Agency

• “As part of the material world, bodily processes are biologically programed in ways over which human beings have limited control.” 
• “Behavior that is not the direct result of a biological process, is, by definition, the expression of an autonomous human being, a manifestation of human agency.”

Moncrieff appears to be oblivious to all the ways in which humans being have limited control over their psychological processes. Every day in my clinical practice I see individuals held hostage by persistent mood states, by obsessions and compulsions, by hallucinations … individuals driven to such despair by this lack of control over their ‘psychological programming’ that many are tempted to end their lives. If anything, these are manifestations of how autonomy and agency is being compromised.

Moncrieff also appears to think that functional seizures are the result of “activity initiated by an autonomous self-directing individual” which makes me wonder if Moncrieff appreciates the radical difference between someone who is faking seizures for secondary gain and someone whose conscious behavior is over-taken by (seized by!) violent movements with no sense of control. 

The Role of Scientific Inquiry

• “mental states and events are not independent entities that can be discovered and described by natural science”

If this is true, it is unclear what legitimate role is left for scientific inquiry in the realm of the psychological. Moncrieff’s views present a challenge to the entire field of scientific psychology, with the implication that scientific psychology, employing the methods of natural science, is engaged in an impossible task.  I suspect Moncrieff might agree that scientific psychology employing the methods of natural science is indeed an impossible task, but I think this implication is important to make explicit for scientifically inclined readers who might not have registered the radical implication otherwise.  

Another Example: Neuroticism

Consider neuroticism, which is a personality trait. It can be defined as the tendency to experience frequent, intense negative emotions associated with a sense of uncontrollability in response to stress. Although neuroticism is considered a risk factor for the development of mental disorders, it is by itself not considered a mental disorder. It is – what Moncrieff says about mental disorders – “part of the range of ways in which human beings live within, and interact with, their world.” Does this mean that it “cannot be discovered and described by natural science”? While it may be true that a complete understanding of neuroticism may elude natural science, the scientific method can nonetheless help illuminate the nature of neuroticism and how neuroticism develops as a result of genetic, neurobiological, and environmental contributions. Neuroticism is not a disease, but it is substantially influenced by genetics. Neuroticism is “mental”, but it cannot meaningfully be described as “self-directed”. It firmly resides in the large space in between the false binary of bodily processes (diseases) and self-directed behavior.

Clarificatory Remarks 

The preceding discussion is not meant to imply that I agree with the portrayal of mental disorders as “brain diseases”, especially when it refers to simplistic notions such as depression being caused by “serotonin deficiency” or schizophrenia being caused by “dopamine excess”. One can be skeptical about explanations that reduce psychiatric disorders to biological abnormalities, but nonetheless maintain the view that psychiatric disorders have complex causation and that biological processes are of explanatory relevance. 
[See also: Interview with Joanna Moncrieff for my series "Conversations in Critical Psychiatry" in Psychiatric Times]

I would like to thank G. Scott Waterman for his helpful comments on an earlier draft of this post.