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The Conceptualization of Problem Behavior as Mental Illness during the Course of History

Nowadays certain forms of feelings and behavior are considered an expression of mental illness, that is, conceptualized as belonging in the medical-psychiatric realm. Whoever opposes this, and who believes that a different context, for instance religious or sociological, is more appropriate, is challenged to choose a different name for such feelings and behavior. I will follow the custom of using the word madness. Thus madness here means such behavior and feelings, without any implication about how they should be conceptualized. I use the term here in a purely descriptive way, with no other connotations, as a Stichwort [key word].

Szasz maintains that only an aberration of the body that can be physicochemically established qualifies as a disease. (See Chapter I, 4.2.1.) A comparable definition was proposed by Virchow, who asserted that all pathology is actually cell pathology. Such a definition could be formulated only after systematic postmortem research on the body became possible. In our culture that was scarcely possible before the nineteenth century. Thus Virchow’s description of illness is the first that is empirically based.

Szasz asserts that conceptualizing madness as mental illness is only possible by expanding Virchow’s description to include not only aberrations of the body’s form and structure, but also aberrations of its functioning, and of behavior. This implies that according to Szasz, hysteria is considered a mental illness only since Charcot’s time.

Was madness considered the same as mental illness? Szasz posits that going back in time to before the eighteenth century to answer this question is pointless. The reason is the validity of the question: before this time, there was no concept of illness the way it is understood in modern (physical) science. There is little reason to fault such reasoning, insofar as everyone is free to be interested only in the modern scientific development of medicine and psychiatry. Ellenberger, too, is of the opinion that scientific psychiatry originated around the year 1800, although he traces precursors already several centuries earlier. However, this form of reasoning has one important flaw: the concept of illness existed much longer than that. References to illness can be found in the earliest dawning of history. And even though in those days it could not be described in a way that meets modern scientific criteria, nevertheless certain forms of behavior and feeling were demarcated from other forms by this abstraction. In addition, the Corpus Hippocraticum, for example, contains elements of scientific methods. Therefore the choice of a specific moment in history as the ostensible starting point of scientific medicine is inescapably arbitrary. This means that the developing modern physical science was not at liberty to define the concept, but was challenged to come up with as good a redefinition as possible. Virchow’s redefinition was an induction. As it was demonstrated that illness coincided with bodily aberrations, the conclusion that such aberrations were imperative for illness to exist seemed justified. However, in the nineteenth century an additional hypothesis was necessary to prevent certain irrefutable illnesses from being excluded from this definition. That was the hypothesis that when bodily aberrations could not be found, they might as yet be determined in the future when improved research methods and techniques would become available.

Modern science, which is still developing, was and is still challenged with the task of redefining disease as it was understood in more primitive science, or if preferred, pre-science. (See also Chapter V, 2.2.) In continued attempts to redefine it, there is an exchange between scientific and pre-scientific (lay) concepts. It would be incorrect for modern science to assume a monopoly on the right to define illness. It would be even less correct to assume that that definition applied before the advent of modern science. An example would be the “Whig-interpretation” which I mentioned in the introduction when referring to Schoeneman.

This can be considered a problem of language, and also of authority. To whom do we attribute the power to determine the meanings of words? There is also a moral aspect, inasmuch as valuing one’s own views so much more highly than those of yore that one does not consider it worth the bother to judge former views on their own merit, is a matter of hubris.

This leads me to the position that the conceptualization of certain behaviors as diseases in former times is not only historically valid, but also relevant to forming current ideas on the matter from a historical perspective.

Indeed, there is unanimity that madness, or certain forms of it, was considered a disease in various places as early as the fourth century before Christ, Hippocrates’s era, and possibly earlier. Moreover, physicians considered it a legitimate object of their care and concern. However, this position warrants noting certain qualifications.
  1. The current segregation of mental and physical illness exists by the grace of Cartesian dualism and the development of the sciences of the last few centuries.
  2. This segregation requires the premise that it is legitimately possible to think of the body and the mind separately to the point that one can be considered “ill” while the other remains “healthy.” When the above manipulation is invalidated and the phenomenon of being ill is observed, this segregation becomes untenable. (See Chapter V, 2.) Szasz’s position – that the body can be ill without the mind, but the mind cannot likewise be ill without the body because the mind is a different kind of entity than the body, which in my opinion implies an asymmetric dualism – also seems to me untenable. Disregarding plants and animals, only a person can be ill, not a body or a mind. Szasz’s premise that disease is an aberration of the body compels him to make statements as, “Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms.” (Ideology and Insanity, p. 15.) This, too, is an untenable position.
  3. Before the eighteenth century, there was little knowledge about physical aberrations and their connection to disease.
These qualifications made insight into any difference between physical and psychiatric disorders incomparable to modern insights. For instance, for a long time the theory of the four body humors dominated medical thinking. When melancholy was associated with an excess of black bile, that was done without too much worry over how the one phenomenon (melancholy) was related to or resulted from the other (excess of black bile). This does not diminish the fact that formerly several forms of madness were considered disease and treated as such.

History is rich in examples of madness medically conceptualized as illness. Ellenberger relates that in chapters on medicine in Greek and Roman literature psychiatric disorders were described among other illnesses. There was no separate psychiatric system. Other classification systems were used according to whichever philosophy was maintained. The same holds true for Arabic and Persian medicine in the early Middle Ages. In the West views on madness during the Middle Ages were totally dominated by explanations and interpretations that were offered by the Church. Allderidge stated that in the early Middle Ages and after, the mad were often viewed and treated the same as other ill people, and presents several examples. Beek and Neaman each dedicate a chapter of their respective books to the involvement of physicians with the mentally ill during the Middle Ages. Somatic medicine flowered in the Renaissance. In that period, madness was increasingly associated with disorders of the nervous system and thus considered a disease. In the eighteenth century De Sauvages included psychiatric disorders in his classification of illnesses. These matters are of course described much more thoroughly in books about the history of psychiatry. This brief summary suffices here, because I merely wish to illustrate that the medical concept of madness was not at all new in the nineteenth century, and in fact was a repetition of an association that was made many times previously. Sarbin, who, like Szasz, opines that mental illness does not exist and is a myth, explains the medicalization of madness similarly to Szasz. However, he illustrates his point with a different historical event. In the sixteenth century Teresa of Avila was challenged with the task of saving a group of nuns, who, according to Sarbin, could be described as hysterical, from the clutches of the Inquisition. She did so by declaring that their behavior was generated by natural causes and should therefore be considered illness. This tactic was successful. According to Sarbin, the metaphorical nature of the illness explanation of behavior became lost in the course of time, thus such behavior became “real” disease. Sarbin and Szasz both regard strategic motives to be involved in medicalization: both Charcot and Teresa of Avila aspired to improving the fate of their respective wards. It seems exaggerated to me to attribute a conceptualization, of which Sarbin evidently does not approve, to one particular historical event. This is all the more so as the conceptualization of madness as mental illness is not an isolated incident, but recurs throughout history.

Equally conspicuous as the conceptualization of madness as illness is the fact that almost never was it the only, or even the most prominent conceptualization. First of all, there were the religious explanations. Van Dijk lists three views that recur throughout history, sometimes separately, sometimes running through each other, sometimes conflicting. They are the empirical-medical, the religious, and the humanitarian approaches. Different explanations dominated in different time periods. In ours the scale has almost entirely tilted towards the medical-empirical explanation with its two variations: the physicochemical and the sociopsychological. Although demonological explanations have not disappeared completely in our culture, as for instance, occur in the Pentecostal and Christian Science communities, these are generally considered relicts rather than conceptualizations to be taken seriously. So the medical view has nearly become dogma, though in the eighties [of the twentieth century] perhaps slightly less. (See section 3.)

On the side, it is interesting to note in view of Van Dijk’s position, that Szasz up to a certain point can be characterized as a modern representative of the humanitarian view, that regards: “…the psychically disordered person primarily as a fellow human being, who has the right to be treated humanely, with as many rights and privileges as possible in common with those who have not been stricken by illness. The approach is to console, encourage, offer safety, motivate, and educate. Reduction to an object, contempt, humiliation, and brutality are rejected. The shared responsibility of the professional and the client is emphasized, and an appeal is made to all healthy powers that are still present.” This quote can be applied to Szasz inasmuch as he advocates a humanitarian approach to these fellow human beings. And inasmuch as that is the case, Szasz can be considered the epitome of the humanitarian tradition that opposes the medical-psychiatric model. However there are also differences between Szasz’s views and Van Dijk’s sketch, which will be discussed in Chapter VI, 4.

An important implication of the above is that Szasz’s view that madness became mental illness by Charcot’s maneuver regarding hysteria, or more generally by expanding Virchow’s definition of disease to include functional disorders, is untenable. The historical development teaches us that it would be more correct to say that in Virchow’s redefinition of disease, influenced by nineteenth century positivism, psychiatric disorders would have largely fallen by the wayside.

It is therefore a toss-up whether we are speaking of a maneuver by Charcot to (re)absorb them into the concept of disease, or a maneuver by Virchow resulting in their exclusion therefrom. We are not dealing with facts that can be proved or disproved, but with different views regarding how a complex concept as illness should be (re)defined. There will be more on this in Chapter V.

In conclusion, madness, nowadays commonly conceptualized as a psychiatric disorder, was regularly regarded and treated as disease throughout history. Before the nineteenth century, this way of looking at it was one among many, often not the dominating one. In the twentieth century the scale tilted almost completely towards medical-psychiatric conceptualization.
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