The concept of mental health – and even more so its converse of mental illness – has become ubiquitous in the modern West, and it deserves serious examination by philosophers. Many, probably most, cultures would not recognize the claim that a mind that sees demons or refuses to speak or commits suicide is in a condition analogous to a body with a fever or a broken limb.
The idea of mental health and illness is the central idea in the psychological approach that we typically refer to as the medical model. The term “medical model”, in its most basic sense, means that one approaches a given field of human endeavour in the manner associated with medicine: that field may then be considered a part of medicine, or simply analogous to it. I believe the term was coined by R.D. Laing, the prominent critic of psychiatry, and so it often takes on a negative cast, for the application of specific aspects of modern medicine in areas where it is inappropriate to do so.
It does not have to, though. Unless we reject modern medicine in its entirety (which would be a stupid idea), we are going to accept some aspects of the medical model for at least the practice of medicine itself. Modern medicine has accomplished a great deal, even in its application to phenomena of the mind: antipsychotics and antidepressants are not cure-alls by any means, but for a great many people, their mental lives are much improved as a result of these medicines.
Moreover, the term “medical model” is used, and I think rightly used, to describe certain philosophical approaches from long before the rise of modern medicine. The medical model as we know it was certainly a shift from earlier Western ways of viewing harmful mental abnormalities, sometimes regarded as sin or as demonic possession. But it is important that medical models of the mind as such are not a modern Western invention.
Consider the Buddhist Four Noble Truths, often stated in the one-word summaries of dukkha, samudaya, nirodha, magga: suffering, origin, cessation, path out. These four could describe the components of medical practice: diagnosis, etiology, prognosis, treatment. In both medicine and the Buddhist dhamma, one identifies the basic problem, its cause, its future course, and what to do about it. And I’m hardly the first to observe this similarity. The observation doesn’t just show up in a lot of Western introductions to Buddhism; it was made by Buddhaghosa, the preeminent Theravāda philosopher, himself. He proclaims that “the truth of suffering is like the disease, the truth of origin is like the disease’s cause, the truth of cessation is like the relief of the disease, and the truth of path is like the medicine.” (Visuddhimagga 512.8-9)
Buddhaghosa, then, explicitly treats a core teaching of the dhamma as analogous to medicine. We have a medical model for our mentally caused suffering and how to get out of it. And Buddhaghosa is hardly alone in this. An article by Albrecht Wezler (Indologica Taurinensia 12 (1984)) goes into marvelous detail on how this fourfold model shows up not only in Buddhist texts but in medical literature (the Caraka Saṃhita) and non-Buddhist philosophical texts like the Yoga Bhāṣya and Nyāya Bhāṣya. Intriguingly, though, Wezler notes that the Four Noble Truths are the earliest attested form of this model: that is, it appears in them before the medical literature. So it could be that rather than Buddhist treatment of the mind being originally modelled on Indian medicine, it was vice versa.
Nor was the idea of a medical model unknown in the West. The Hellenistic philosophers (the Stoics, Epicureans, and Skeptics), referred to their philosophies as therapeia, the Greek word for medical care, and the root of our modern word therapy. Thus Martha Nussbaum entitled her excellent book on these thinkers The Therapy of Desire. In it, she shows how the Hellenistics believed that we are in some significant way sick, and philosophy offered a way of treating it.
The Hellenistics and Indians did not model their philosophical paths on modern experimentally based medicine, but they did see the paths as analogous to medicine nonetheless. There remains one big difference from the modern medical model of mental health, though. And that is that the Four Noble Truths are a diagnosis, etiology, prognosis and treatment of the normal human condition. That is also how the Hellenistics viewed their philosophical therapy: it could benefit everyone. The modern medical model, by contrast, has viewed “mental health” as the normal state of being. And, it seems to me, that is what it gets wrong!
Even when applied to physical health, there is something a little strange about the word “health” being used as a binary: you’re healthy or sick. As one goes through one’s forties and fifties and the daily medications one takes for minor troubles begin to add up, it’s hard to see the divide being so clear-cut. Surely health is more of a continuum. But even if one can accept that a typical twentysomething is physically “healthy”, it’s still not so clear how that term can apply to the mind.
Martin Seligman founded the flourishing field of positive psychology out of frustration with this approach. Psychology had traditionally viewed itself as “curing” the “sick”: taking you from an unusual state in which you had a “disorder” into a normal state of “health”. But when Seligman, a lifelong “grouch”, observed that his five-year-old daughter had done more work on improving her mood than he had as a trained psychologist, he realized something was wrong. One could be perfectly “mentally healthy”, on 20th-century psychology’s model, and still be miserable – or still be a jerk.
It is for this reason that a stigma has long been attached to seeing a therapist: to do so was to indicate that you were “crazy”. It seems that these days the stigma is diminishing – many current pop songs mention seeing a therapist – and I think that is a great thing. The ability to talk out one’s mental problems and find solutions is valuable for most if not all people, not just “crazy” ones. But the “crazy” view of therapy is the logical conclusion of a model that views mental health as normal, and “mental illness” as a deviation from that norm: a model that divides the world into normal people and crazy people. The classical Buddhist model is much wiser when it tells us: we are all crazy. Some of us are just crazier than others.
Pingback: Of mental health and medical models – The Indian Philosophy Blog
A few thoughts that came to mind after reading this post:
First, I want to mention that Bhikkhu Anālayo published a memorable little paper (including a translation of the “Discourse on the physician”) about the medical analogy in the four truths: “Right view and the scheme of the four truths in early Buddhism: the Samyukta-āgama parallel to the Sammāditthi-sutta and the simile of the four skills of a physician”, Canadian Journal of Buddhist Studies, 7, 2011, 11–44.
Second, by the 1960s humanistic psychology, associated with psychologists like Abraham Maslow and Carl Rogers, came to be very influential and was widely seen as a third alternative to the behavioristic and psychoanalytic theories that had dominated psychiatry and clinical psychology before then. For example, here’s something that Maslow wrote in his foreword to a 1965 book by Andras Angyal, a psychiatrist who has been called part of the humanistic movement:
“Even though he hasn’t spelled it out, it is easy enough to discern his dissatisfaction with the medical model of psychological illness and therapy. His conception of neurosis as a total Weltanschauung, a life-philosophy, or a personal unconscious mythology, has many consequences for our conceptions of ‘symptoms’ and of ‘illness’, of the ‘therapist’s’ role in ‘treatment’, of the meaning of ‘cure’. Each of these words are now moot, transitional, obsolescent. For my part, I dislike them all—as representing a condescending authoritarian attitude of an over-proud person to an over-humble person—and I suspect Angyal did too. … What is it that makes us reject as inadequate the division of people into ‘normal people’ and ‘patients’? It is not an absence of differences between these two groups but the presence of major similarities. All human beings share the human condition and the common human fate of growth, joy, pain, grief, death. In this respect we are all alike, therapists and patients. … Angyal’s thesis that the human strivings, the basic motivational trends, are identical in neurosis and in health provides this feeling of fellowship with a sound theoretical basis. Yet anyone who would conclude from this that Angyal tends to minimize the difference between neurosis and health would be mistaken. He never tired of pointing out the magnitude of the handicap neurosis creates and the monstrous waste of human life in which it results …”
With the rise of humanistic psychology, mental growth became a prominent metaphor in psychotherapy alongside mental health. This can be seen in the title and subject of a paper by two psychologists known for their fusion of (among other things) humanistic psychology with the developmental psychology of Jean Piaget: Laura Rogers & Robert Kegan, “‘Mental growth’ and ‘mental health’ as distinct concepts in the study of developmental psychopathology: theory, research, and clinical implications”, in Daniel Keating & Hugh Rosen (eds.), Constructivist Perspectives on Developmental Psychopathology and Atypical Development (pp. 103–148), Hillsdale, NJ: Lawrence Erlbaum Associates, 1991. Rogers & Kegan began their paper by asking:
“What is the relationship of mental growth to mental health? The underlying assumption of Piagetian psychology is that as intellectual development proceeds, the organism makes a better adaptation to the environment. However, as we grow in mental complexity and organizational capacity do we indeed become more healthy mentally? And conversely, are failures of adaptation necessarily failures of development?”
Those are good questions that you may want to consider, for certainly Buddhism also has rich traditions of promoting mental growth. (I could say more about this but I’m saying too much already.)
I have mentioned before a book by Michael Basseches & Michael Mascolo, Psychotherapy as a Developmental Process (Routledge, 2009). Basseches and Mascolo take a perspective that focuses on mental growth, rigorously defined, as the process of psychotherapy.
Focusing on mental growth instead of mental health would change the last two sentences of your blog post significantly. Instead of “we are all crazy; some of us are just crazier than others” it would read something like: “we all have room for growth; some of us just have more room for growth than others”. I think something like this would be an improvement because it would avoid the negative effects of unnecessarily pathologizing language that the humanistic psychology movement had already recognized long ago. If psychotherapy has become more popular over the decades, it is because, thanks in part to the humanistic psychology movement, more people have come to see therapy as an opportunity for growth and not because more people have come to see themselves as crazy. That doesn’t mean that the possibility of severe pathology is denied by an emphasis on mental growth; in the quotation from Maslow above you can see how Maslow was keen to recognize severe problems. But without a strong conception of mental growth/development, it’s easy to get trapped in the mental health/illness duality, and to say that “we are all crazy” is to still be stuck in that duality, it seems to me.
I’m generally sympathetic to the idea of speaking of mental growth rather than mental health. “We are all crazy” is something of a shorthand. But I wouldn’t want to put it as “we all have room for growth”. That makes the changes sound optional. It doesn’t adequately convey just how much we can be our own worst enemies. Maybe something like “we all desperately need to grow, some more desperately than others.”
Yes, I like that reformulation. As Norman Fischer put it, “Recognize that mind training is not optional, it is essential. Everything in your life depends on it.”
I wanted to add that this topic should also be connected to the issues you raised in your post “Is the problem in our heads?” If psychotherapists suddenly found themselves overbooked during the COVID-19 pandemic, for example, was it because the problems were all in people’s heads? I mentioned the psychiatrist Andras Angyal above; one of the sections in one of Angyal’s books (Foundations for a Science of Personality, Oxford University Press, 1941) is titled “Organism and environment are not separable as structures in space”.
Well, the problems the psychotherapists were overbooked about were in people’s heads! The ones that weren’t in people’s heads were ones that they went to other kinds of doctors for. Everyone reacted to the pandemic differently, most of us badly. Nothing about the event necessitated fear or frustration, but that is how most of us were built to react to it.
I elaborated on these points a bit more in a followup to the “in our heads” post: frustration and suffering happen when our inner mental states of craving and resistance bump up against undesired events in the world. Some of those events are more undesired than others, but we can’t change the world to get rid of them. Theoretically if we could do that then the solution would be in the world, but we can’t.
I don’t know exactly why many psychotherapists saw an increase in demand for their services during the pandemic, which was why I phrased it as a question, but what I had in mind in particular is that human interactions are not in people’s heads, and a person’s act of reaching out to a helping professional when other key relationships have been lost is a way of solving a problem by changing the world. It changes the world in a small way, but it still changes the world. This is also evident in any patient–physician interaction, but it can be overlooked by an exclusive emphasis on inner change.
Sure, that’s fair. To fix the problems in people’s heads often does require outside help. Pratyeka buddhas are among the rarest creatures of all.
I was poking around on the web and found a recent Chicago Tribune article titled “In a pandemic, people might know they need food or housing. But how do you help them realize they also need therapy?” that began and ended with a profile of a therapy client who emphasized mental growth:
“As the pandemic wore on, Kayode Martin felt stuck. He’d graduated virtually, a high school senior when COVID-19 arrived in Chicago. A year later, in 2021, he was working at a store but struggling to find a routine that felt on good footing. When his grandfather told him about a construction training program at the Inner-City Muslim Action Network, he applied. During the intake process, a social worker there also suggested counseling, and the 19-year-old was connected with therapy. … For Martin, several months of therapy helped him open up to others in his life, like his mother. He feels stable, not so stuck. ‘I feel like I’m evolving now,’ he said.”
Also, I want to point out that in your followup to your post “Is the problem in our heads?”, which you mentioned above, you concluded that “the solution, according to the classical Buddhist texts, is in our minds”. However, the current post is about the modern world, not the classical Buddhist world, and as I noted in my comment on “Is the problem in our heads?”, modern psychologists have determined that the treatment of certain problems involves changing the environment, not just the head. Whether the solution is in the head or in the world or in some combination of the two depends on the problem. Angyal was among the psychiatrists who provided a theoretical explanation for this.