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Causality and Responsibility
Regarding Psychiatric Disorders

Szasz posits that in the absence of organic aberrations there is no objective ground for not holding people responsible for their actions. Below I will begin by discussing two ways of looking at psychiatric disorders, unreason (A) and unfreedom (B). After that I will illustrate, using some psychiatric disorders as examples how this way of looking at them seems to the psychiatrist and the patient (C). Next I will examine whether the criterion is reliable and valid by looking for signs that psychiatrists are prejudiced (D). Finally, I will examine in which situations it can be sensible to maintain the criterion (E).

A. Psychiatric Disorders as Irrationality

The former view that psychiatric disorders mean that the person so disposed is incapable of acting as a rational being has recently found an advocate, namely Moore. As Moore’s position contradicts Szasz’s that hysterical patients are acting rationally and purposefully it is worthwhile to examine it more closely.

Moore defines the concept of rationality broadly. He reasons as follows. For a certain behavior to be considered rational there must be a motive. Secondly there must be goal. Thirdly there must be a number of beliefs such as that a certain intervention in a certain situation will achieve the desired goal. Fourthly there must be a view and interpretation of the circumstances. Fifthly this chain must not be broken by other motives that might lead to different actions. Behavior is rational only when with all five of these components comply with the criterion of rationality. Edwards even distinguishes seven components. By that he poses such high requirements for the criterion of rationality that he is compelled to admit that most people are not very rational. Moore’s premise is that a person’s rationality is a function of the rationality of his actions. The less rational the behavior the less rational is the person who displays it. When someone’s capacity for rational behavior declines it means that that person himself is irrational, which is the same as saying that the person is psychiatrically disordered, and cannot be considered responsible for his behavior. Moore concludes, “In this, the mentally ill join (to a decreasing degree) infants, wild beasts, plants, and stones,” which prompts Szasz to remark that Moore’s concept of mental illness is indeed dehumanizing (Psychiatric Slavery, p. 7).

It is worthwhile to follow Moore’s reasoning more closely, in particular the first four steps which he considers as leading to irrational behavior.

In the first place, there is the action’s motive and the purpose related to it. Moore posits that the conscious motive must be considered first. When that is not done the motive must be elicited from the action itself. It is all too easy, according to Moore, to find a motive for whatever behavior and assume that the consequences of that behavior are the goal. (See Chapter IV, 3.2.) That way every behavior can be considered rational but in a thoroughly speculative sense.

In my opinion Moore’s position implies that anything which is not directly comprehensible must be labeled unintelligible. Moore is actually saying that every dissociation from reality, every “Term II” according to Perelman (see Chapter IV, 3.2), is not only necessarily speculative but also should not change our views on the rationality of behavior. Moore’s requirement implies that only immediate reality may count as a basis for our assessment about others’ behavior. Highly speculative and unlikely theories explaining human behavior have been posited. This does not have to mean that every explanation is out of bounds. Speculations about “Term II” can after all not be verified as true or untrue, but they can be evaluated for their utility. Freud’s concept of the unconscious, for instance, as a “Term II” concept, has greatly expanded our insights into behaviors that are at first glance unintelligible. The motives and goals can thus be made understandable. This does not mean that they are also rational. It would be impossible to prove that all human motives are rational. Man is a rational being but he is much more than that. Many of his motives are not rational, although comprehensible, and as in the phenomenological approach, we can identify with them. Moore does not claim that man is a rational being, only that a person with a psychiatric disorder is less rational than other people.

It does not seem particularly reasonable to me to follow Moore and reject a plausible explanation of human behavior that provides insight into primary motives and goals and which in addition proves effective in treatment, as soon as such behavior must be judged rational or irrational. Such an explanation does not make irrational behavior more rational, but it also does not make it less rational. In other words, it can be understood in a way that is comparable to the way rational behavior is understood.

Weinberg et al, attempting to defend Szasz’s position on Moore, employ yet another argument. Using the conscious motive as a premise necessarily implies that the claimed motive is indeed the true motive. They assert that Szasz impugns that someone’s claims may or may not reflect his true motives and that therefore in principle the motive can never be determined with certainty. Although this reasoning undoubtedly has relevant and sensible elements, to me it seems to imply that someone’s claim must never be accepted as a valid motive for his actions and thus that the person in principle must never be believed. Instead only the effects of his actions should be considered (as already discussed in Chapter IV, 3.2.10c). The ultimate consequence of such a viewpoint is that just about any verbal communication is rendered senseless.

Moore’s arguments regarding presumptions and beliefs that contribute to behavior seem valid. The epitome of a belief with a subjective reality value that can lead to irrational actions is the delusion. In typical cases the content of such a delusion may be patently absurd and at the same time the person is immovably convinced of its validity, thus making the impression of being extremely irrational. The problem here is that many people have ideas and convictions that are irrational. For example, the multiplicity of religious convictions and ideas is irrational when the rational premise that at most one of these can be true is chosen. The same holds true for the various political convictions. Kuiper mentions the example of a general who speculates on the consequences of an atomic war and who considers millions of deaths acceptable in such an event. Kuiper asks whether this involves a case of rational or delusional judgment. The convictions held in Nazi Germany regarding Jews and the superiority of the Arian race can also be considered examples of absurd, irrational convictions. This means that whoever wishes to maintain the criterion of rationality as opposed to delusion must point out its individual, subjective nature. It is a belief that someone has but shares with no one. Even then the clarity is more apparent than real. The folie à deux is an intermediate form. Furthermore, due to delusions’ formal features – their place in the totality of experiences and the relatively stereotypical and unchangeable content, including over time – they could exist alongside a similar reality. For instance the infidelity delusion (the immovable belief that the spouse is unfaithful) can also exist when the spouse is in fact unfaithful. If this is true then not the actual content of the delusion is most important but the form in which it manifests itself. In addition, certain convictions, for instance that the earth is round and rotates around the sun, were at certain times considered not only dangerous but also irrational, while at other times were considered perfectly rational. So a social-cultural factor is always involved in the assessment of a delusion. Finally, it is true of delusion as well that seeking its purpose reveals viewpoints, for instance in a psychoanalytical context, that can shed light on how to understand the contents of the delusion making it seem less irrational.

Two kinds of rational behavior can be distinguished here. Behavior can be rational given a certain conviction (such as a delusion or an opinion). At the same time this same behavior can be futile depending on the rationality of the conviction itself, or irrational, if no reasonably rational person shares the conviction. Mullane defends the view that neurotic behavior is irrational because the motives are unconscious and because the process of the motives becoming unconscious is “automatic,” that is, transpires independently from the person’s conscious volition. His view implies that a causal-analytical explanation is applicable. It seems to me, however, that a motive becoming unconscious can be seen as something that happens to a person but also as something that he does or causes. There is no point in ascribing irrationality to neurotic behavior as Mullane does anymore that there is a point in ascribing rationality or irrationality to the growth of a plant or the growth of a tumor. Mullane seems not in fact to speak about whether neurotic behavior is rational or irrational but about the freedom of choice regarding neurotic behavior. This is a different way of looking at psychiatric disorders which will be discussed shortly.

As to the visualization and interpretation of the situation in which one finds himself – the context in which a certain behavior can lead to a certain goal – many internal and external factors that have no relation whatsoever to reason may influence such circumstances. The emotional state, previous experiences under similar circumstances, physical state (the thirsty will look everywhere for a drink), and the strangeness or familiarity of the situation can, when considered, suddenly clarify that which at first seemed irrational. Many mistakes in evaluating reality have nothing to do with (ir)rationality, such as those caused by disabilities of the senses or hallucinations. “Reality testing,” the skill to distinguish between stimuli from the environment and stimuli from within, is extraordinarily complicated and vulnerable, (ir)rationality having little to do with it. The significance of “beliefs” has already been discussed.

It is peculiar that Moore does not explicitly address the disorders of thought that can occur in psychiatric disorders. Such disorders may cause conclusions to be drawn that do not rationally follow the premises. After all, irrationality is essentially a disorder of reason or of cognizance. It might be expected that disorders of thought would be the primary and central focus. However, here too closer examination reveals that there are all kinds of possible explanations that can clarify and furnish insight into such incorrect conclusions.

Moore’s statement that people with psychiatric disorders are less rational than other people compels us to make a comparison and thus to determine a base rationality in a social and cultural context. Obviously, it is impossible for anyone to exit this context, which would be required in order to assess it objectively. This limits the criterion. Even though in theory it might be value-free it can at no time be practiced value-free in society. In other words, Moore cannot escape basing the test for rationality on his own motives, goals, beliefs, convictions, and interpretations. The less similar to Moore’s thoughts the other person’s are, the less rational (more ill) the other is. A value system is concealed in the apparently value-free terminology of (ir)rationality. It is this value system which is decisive for considering a person irrational. In my opinion, it is inadmissible that Moore links this irrationality to the conclusion that the mentally ill are less human than other people, and resemble children or wild animals (!) more than they.

Two examples demonstrate that irrationality can also be a factor in medicine and psychiatry. The first is Rooymans’ remark that clinical judgment is not rational. The other is Van Nieuwenhuizen’s contention that the subdivision of diseases among the various branches of medicine is not rational.

My commentary on Moore’s reasoning is not intended to deny that psychiatric disorders can involve irrationality. I only wish to point out that developments in psychology, sociology, and psychiatry have generated so much information, and explanatory theories have shed so much new light on the “method in madness” as well as on the irrationality of normal people, that irrationality as a criterion for psychiatric disorder is untenable. It is a fruitful point of view in curative psychiatry and has stimulated the formulation of all sorts of theories. But it is in no way a criterion that has sufficient reality value to serve as an ontological base for the concept of psychiatric disorder.

Moreover, human behavior and experience have a very important symbolic significance in addition to literal meaning. “Except for the immediate satisfaction of biological needs, man lives in a world not of things but of symbols.” Both in psychiatry and everywhere else it is important to realize that language and behavior have symbolic meanings to an important degree. This implies that what a person says or does has a communicative meaning that is sometimes quite clear and other times difficult to unravel. Symbolization is not only about what words and things are but even more about what they mean. Psychotic people often use unusual symbols and are therefore difficult to understand. It can be considered a communicative disability which can be described as a disorder, and therefore becomes treatable. One’s attempts at communication not being understood by others is a source of great suffering. Considering such behavior irrational in the sense that people who behave like that are actually essentially different from other people is like saying that a stick in water is broken because it looks that way. (See Chapter IV, 3.2, 10). It cannot be a justification for viewing people with psychiatric disorders as different than other people and as people to whom all sorts of things should be done that would be inadmissible for everybody else.

B. Psychiatric Disorders as an Obstacle to Freedom

Foucault writes that in the seventeenth and eighteenth centuries the essence of madness was considered unreason, and today, unfreedom. This view of psychiatric disorders, namely, that they are disorders because they limit and impair people’s freedom, seems fairly generally held nowadays. Kubie states, “Freedom to change is the essential tribute of healthy life … the process of mental illness is initiated when anything freezes behavior into forms that can no longer change.” Furlong quotes Whitaker as saying, “Wellness is perceived as fundamentally the increasing capacity to choose. Shorn of all its frills, sickness is perceived as any hindrance to free choice.” Szasz tells us, “What distinguishes the varied phenomena that may be classed as psychiatric symptoms? All entail an essential restriction of the patient’s freedom to engage in conduct available to others similarly situated in this society.” (The Ethics of Psychoanalysis, p. 14). Keeping in mind the description in 2.1, being psychiatrically ill would have to be described as: a process in which the freedom to make choices and creative adaptations inside the potential range in which the person might be capable of doing so is restricted in such a way as to engender suffering, dysfunction, and abnormality. The person behaves as he does because he is not capable of behaving differently. Freedom has been replaced by determination.

When unfreedom, rigidity, incapacity to grow and change, and incapacity to creatively adapt (creative meaning adjusted to the unique constellation of actual circumstances) are viewed as the common denominator of psychiatric disorders, established psychiatric theories generally explain them very well. Psychoanalytic, humanistic, psychological, and social theories, as well as integration, family interaction, and Janet’s theories each explain psychiatric symptoms and behavior differently, but all share the notion that a person is disordered only when he behaves in a certain way because he cannot behave in any other way.

The restriction on freedom, and obviously also the measure to which a person can be held responsible for his behavior, are considered to correspond to the unfreedom generated by organic aberrations in physical disease. Logically speaking, assuming restriction on freedom is inescapable. If symptoms are chosen purposefully then such behavior, even when it is aberrant or unconventional, cannot be considered ill. Therefore I will below assume that psychiatric disorders are restrictions or impairments of a person’s freedom and autonomy as a practical hypothesis for the purpose of examining to what degree this definition is useful and sensible. In Chapter VI I will discuss dealing with this basic notion in practice.

C. Examination of Restriction of Freedom in Various Psychiatric Disorders

How is freedom restricted in psychiatric disorders? I will illustrate this using examples in order of increasing levels of restriction of freedom.

In what the DSM-III calls “major depression with melancholia” patients may feel overwhelmed by severely depressed mood and inhibition which deprive them of all happiness, initiative, and activity. Their lives are a torment for reasons totally obscure to them and the people around them. They are helpless to overcome the situation. The same holds true for psychotic disintegration, in particular when there is no discernible relation between behavior and intention. Perhaps the prototype of psychical inflexibility is the delusion that occupies a person’s attention for years without the least change. Some psychotic people complain that their thoughts are manipulated or that they are compelled to obey voices. These are explicit cases of (the experience of) unfreedom. However, when someone is thoroughly convinced of experiences which others call crazy and the psychiatrist calls psychotic while not experiencing unfreedom, the situation becomes more difficult. How, then, do we determine whether that person is free or not? We can do so by comparing pre-disease functioning with current functioning. An example is the querulous delusion in which a person for years fills his life with attempts to obtain redress and revenge for an imaginary injustice done to him, or perhaps a real but trivial injustice. His behavior is rigid and stereotypical.

Compulsive thoughts and actions are less problematic in this aspect. Patients complain that they are compelled to constantly and endlessly repeat certain thoughts or actions. This is accompanied by an oppressive feeling of unfreedom and senselessness.

Paraphilia, which used to be called perversion, includes several sexual activities such as pedophilia, exhibitionism, and voyeurism. Such behavior is unusual and from a moral viewpoint is certainly not admirable. But does it have anything to do with a limitation of freedom? And if so, then how? It can be stated unequivocally that such behaviors are deviant but if the person who displays them feels that he freely chooses them, why call them psychiatric disorders? It is noteworthy in this regard that in the DSM-III and fairly generally in practice, homosexuality is no longer considered a psychiatric disorder unless it is ego-dystonic. Is homosexuality the first in a row of falling dominoes? Can we expect the other paraphilias will soon also be counted as psychiatric disorders only when they are ego-dystonic?

How, then, should we consider disorders such as pyromania and kleptomania? People who have this behavior express being incapable of resisting the urge to perform certain acts. But they perform them with complete awareness of what they are doing, knowing that their actions are illegal. They do so with planning and care. How can we objectively assess their actions if they claim to be unfree in this aspect?

Then there are the disorders which in the DSM-III are called “factitious disorders.” Examples are Ganser syndrome of which it is still not clear whether the person is performing an act or behaving unfreely, and Munchausen syndrome. In its commentary the DSM-III notes, “The production of psychological symptoms is apparently under the indiviual’s voluntary control.” Apparently these people, through their syndrome are expressing a desire for the sick role though the reason remains unclear. They are willing to sacrifice a great deal for their goal and choose unusual ways. But is there really unfreedom in this?

Finally, there is simulation. This is not considered a psychiatric disorder. The faker has to have a clearly recognizable and demonstrable goal such as rejection for military duty. The difficulty here is the criterion of the recognizable and demonstrable goal. How should a behavioral pattern of claiming physical illness in the absence of physical aberration be considered when the goal served is not recognizable or scarcely demonstrable, for instance when it is trivial?

For this criterion of will or capacity it is essential to ask who is doing the assessment. Is it the patient himself, the people around him, or the psychiatrist? From the perspective of people with psychiatric disorders a feeling of unfreedom, of not being able to do what they want, and being compelled to do things they do not want, of being determined by all sorts of factors that are not authentically their own, is quite consistent. The experience of unfreedom repeatedly appears in psychiatric descriptions of these disorders although it must be noted that this unfreedom is sometimes extremely obvious, sometimes only slight, and sometimes not at all noticeable. So it is not always possible to be objective about this criterion. Psychiatrists’ assessments necessarily contain an element of intersubjectivity. They pass judgment on others’ behavior and on the degree to which those people chose that behavior or were driven to it. There is a large measure of agreement between patients and psychiatrists regarding the measure of unfreedom in behavior that can be labeled a psychiatric disorder. A clear exception to this is when patients experience themselves as not ill and their behavior as authentic while their psychiatrist is of the opinion that they have a psychiatric disorder.

D. Freedom, a Psychiatric Fiction

Are psychiatrists’ opinions impartial and unprejudiced or are there factors that color their views and thus detract from their validity?

Bakker’s research (3.3.2) revealed that psychiatrists are consistently more pessimistic about the their patients’ prognoses than is justified by reality. This would mean that they view their patients as more ill, that is, less free, than they actually are. Bakker mentions that little research has been done regarding the making of psychiatric prognoses. He cites research by Van Bork, Van De Jonghe, and Van Beenen, which all seem to support his own findings, or at least, not contradict them.

Townsend contends that psychiatrists expand the borders of psychiatric illness broader than other people do. He describes the reluctance to recognize psychiatric disorders in other people as fairly high. Once such recognition has been made psychiatrists nearly always confirm it. I would like to add that in psychiatric practice there is generally little attention for the question of whether there is a psychiatric disorder, only which psychiatric disorder. Not infrequently people who are regarded as disordered by others are with great effort urged to go to a psychiatrist, sometimes almost literally being pushed through the clinic door. In such circumstances there is great pressure on psychiatrists to come up with something that can be done for the patient. When viewed from such a perspectiv, there is much less preoccupation with the question of whether there is a psychiatric disorder at all. In such cases the most important function of the diagnosis may be to justify the assistance offered.

There also seems to be a rule in psychiatry, that overlooking a diagnosis is a more serious mistake than making an unjustified diagnosis. The inclination to assume a person is ill unless it is demonstrated that he is not exists throughout medicine, including psychiatry. In psychiatry this means that there is an inclination to assume a person is unfree unless it is demonstrated that he is not. Admittedly, this bias is much more difficult to correct in psychiatry, as, contrary to somatic medicine, there are no more or less objective methods to be used in daily practice that might have a corrective influence (see 3.3.2).

My hypothesis is that one of the reasons that psychiatrists tend to be more pessimistic about their patients, assessing them to be less free and more determined by their illness than they really are, is because most of the explanatory theories at their service are basically deterministic. Immergluck stated, “It would be inconceivable to think of a science of behavior without a systematic deterministic position.”

As to psychoanalytic theory, Furlong notes that although there is not complete consensus on this, the theory leaves no room for true internal freedom. He quotes Holt who says, “There is no tenable alternative to determinism for science. The behavior of the ‘free’ person can be predicted from a knowledge of his past, his structure, need, and presenting situation because it follows lawful regularities just like any other behavior.” Furlong concludes that psychodynamic theory could not explain the contradiction between experienced and obvious freedom, and determinism. He mentions Pavlov and Skinner in particular regarding behavioral science and learning theory. He states, “Absolute determinism is a concept so deeply engrained in the theories, that it is difficult at times to recognize the hidden assumption for what it is.” Those who believe in a social model view the individual’s behavior as the result of a complicated but determined social power game.

I wish to note that obviously whoever wishes to approach experience and behavior scientifically must seek cause-effect relationships and rules. He cannot escape homing in on precisely those forms of experience and behavior that fit the rule or (seem to) confirm it. So that which is determined, or can be assumed to be determined, draws more attention than that which is free, and thus difficult to grasp. If there is such a thing as free will then it cannot manifest itself any other way than in that nebulous realm where rigid rules do not apply.

The forming of psychiatric theories about unfreedom presents itself here as a paradox. On the one hand psychiatric disorders are explained as restrictions on freedom. On the other, established psychiatric theories tend to deny human freedom in general. The more we know about people, the more predictable their behavior is. But if man is in essence not free there is no point in calling the restriction on his freedom disease. This paradox is partly a contradiction and partly not. Undeniably humans do perform a number of acts with a feeling and awareness of freedom and choice while they perform other acts without this experiential feature being clear, or with an obstructive and oppressive absence of any feeling of acting freely.

It is not so important for the enormous significance that this experience of free choice, of doing what one wishes, has for man whether or not it is ultimately based on a scientific fiction. It is, however, a serious drawback of the theory that it can construct no other explanation for human freedom than that it is fictional. In other words, it is a reason to correct the theory rather than allowing it to condemn man to slavery and heteronomy.

A different important consideration is that theories explaining psychiatric disorders as restrictions of freedom are not about being free or unfree but about functioning with a greater or smaller degree of freedom.

Finally, no psychiatric theory has even remotely succeeded in predicting human behavior in all its complexity. The notion that man is determined does not arise from any proof based on this theory but rather from an extrapolation of that which has become known. A number of behaviors can be predicted, for instance, from previous behaviors. The more is known of previous behaviors the better future behavior can be predicted. The inference is that if all previous behaviors are known all future behaviors can be predicted. In theory this situation is unattainable because the prediction itself becomes an experience which contributes to determining behavior, and because the evaluator doing the predictions introduces a complicated network of new experiences.

E. The Contextual Constriction of the Freedom Criterion

In psychoanalytic theory the unfreedom of a person who has a psychiatric disorder is elucidated using the concept of the unconscious. This concept is one of the most basic concepts in today’s psychiatry. It means that all sorts of important feelings and thoughts that people have are partly or wholly unclear to themselves. They cannot access them, so cannot take them into account, but are nonetheless influenced by them. These mental factors remain concealed because they are frightening or unbearable. People can begin to realize what is going on inside of themselves, and unconscious contexts can become conscious, only when an atmosphere of safety and acceptance is achieved.

Psychoanalysis as a therapy is the epitome of a situation in which this atmosphere is achieved. People who submit themselves to psychoanalysis do so because they are burdened by their complaints and problems and because they believe that this treatment can help them. A contractual relationship exists between analysts and analysands by which the analysands regard their analysts as their allies. Confidentiality guarantees that analysts will not use anything analysands say against them. In short, the relationship is ideal for patients to be as candid as possible about themselves. The significance of the unconscious nature of mental factors and processes must be seen in the context of this treatment situation. Also in this situation we discover how extraordinarily difficult it often is for patients to express what is going on inside of them. Obviously, in every other situation this will be even more difficult. This is particularly true when patients’ interests are served or jeopardized by the outcome of the evaluation such as in matters of eligibility, involuntary commitment, or a trial, and they do not know exactly what psychiatrists will do with the information they provide. In such situations it is difficult to extract reliable information about what is conscious and what is unconscious. A person could be presenting a polished image of what is going on inside of him. He could remain silent on some things, twist, or change them. In that case no reliable methods are known for determining to what extent the person’s problems are clear to him and how accurate the picture he presented of his own experience is.

Psychiatrists in general assume that people will inform them as well as possible as that is in their interest. It is however not at all certain that the people themselves always see it that way too. Obviously there is a need to be cautious in assessing what people actually experience, and what is unclear or unconscious, particularly in non-treatment situations. Symptoms and syndromes are important in such situations because the are observable. In conclusion, a reasonably reliable pronouncement on what is going on inside of a patient can be made only when there is unambiguous cooperation between the patient and the examiner. Any other circumstance is in this respect dubious.

From the above the following conclusions can be drawn. In psychiatry people are not considered responsible for their psychiatric disorders in the same way that people are not considered responsible for their illnesses in somatic medicine. The former conviction that people with psychiatric disorders are incapable of acting as reasonable beings is no longer tenable. Nowadays patients are not held responsible for their psychiatric disorders because it is assumed that they are subjected to them involuntarily and are not free to act any differently than they do. Patients themselves often clearly experience unfreedom except in those cases that they do not consider themselves ill or aberrant nor their behaviors strange.

Psychiatrists for their part seem to perceive the realm of psychiatric disorders to be broader than other people perceive it. This inclination may be partly caused by the assumption that patients are to be considered ill unless the contrary is “proven.”

Theories explaining psychiatric disorders tend to view man as determined. Accordingly, the decisive criterion for psychiatric disorders, namely restriction of freedom, risks becoming a fiction in a scientific sense.

An ideal insight into what is going on inside of a person and how much that person is free to shape his own life is possible only when there is optimal cooperation between the patient and the psychiatrist. When cooperation is less than ideal, restriction of freedom can be determined less reliably, even though a certain pronouncement on the matter can be done on the basis of symptoms and syndromes.
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