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Mental Illness as a Moral Concept

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mEDTAllllDESS AS
A
mORAL
[OD[EPT
……………………….

SEAnSAVERS

(,

The concept of mental illness has been the
subject of heated controversy in recent years;
and this debate has caught the attention of a wide
public. The reason for this is not simply that the
debate has sometimes been conducted in heated
terms; but, more importantly, because it has raised
central moral and social issues which are of fundamental concern. And it is in this respect – as an
aspect of contemporary moral and social thought that I wish to look at this controversy in this
paper.

So Jaspers proposes to define illness as deviation
from the average and imagines that by so doing he
has produced a non-evaluative concept of illness.

He is assuming that any concept with objectively
specifiab1e criteria is a non-evaluative one, but
this is a crass error about the nature of value
jUdgements which even our contemporary moral philosophers have avoided. [3] Just because precise and
objective crit~ria can be specified for being Jewish
it does not foilow that anti-Semitism involves no
value-judgements.

Even this intention requires some justification,
however, since moral philosophers have tended to
ignore it or simply parrot what psychiatrists have
to say about it, while most psychiatrists would
dispute that their ideas on mental illness have any
moral significance. Thus it is common for psychiatrists to regard their work as a kind of technology,
which is seen as a means for producing a certain
result (viz. mental health) which can be objectively
defined. And it is often argued that just because
the goal of therapy is ‘objectively defineable’, the
only relevant criterion for evaluating the success of
therapy is in terms of its efficiency in achieving
this ‘objectively defined’ goal, and therefore that
moral considerations do not play any part. According
to this view then, which I shall call the ‘psychiatric account’, a judgement of illness is not a valuejudgement, but an objective and factual one; and
psychiatric theory is a scientific theory which
neither raises nor answers any moral questions.

Health and illness are practical concepts and
the need for them arises in the practical context of
therapy. A purely theoretical science does not require
them, but in the practical, medical sciences they are
necessary to specify the goal and object of therapy.

And so long as health continues to specify the goals
of therapy, and illness continues to specify what is
to be eradicated through therapy, these concepts
will be evaluative ones, regardiess of whether these
goals are precisely defined in empirical terms. These
remarks apply to the concepts of health and illness in
general. In the specific case of mental health and
illness, the value-judgements involved concern a
person’s actions and rationality and his relationship
with others. There are good grounds, therefore, for
regarding mental illness as a moral concept. [4] In
the light of this, the statistical approach is clearly
unsatisfactory: it seems to put an arbitrary value
upon ‘the average’ and claim a mysterious objectivity
for itself in doing so.

Broadly speaking, two sorts of criteria have
been suggested in the attempt to define such an
‘objective’ concept of mental illness: statistical
and clinical. [1]

The virtue of objectivity is also claimed for
the clinical approach, which is altogether a more
sophisticated one according to which illness is
improper or abnormal functioning. This view is best
explained in terms of a frequently used analogy
between curing an illness and repairing a machine.

According to the statistical approach, mental
illness is to be defined in relation to statistical
norms. The main advantage claimed for this sort of
definition is that it involves precise, empirical
criteria. Thus, for example, Jaspers writes:

According to this analogy, the doctor (either in
general medicine or in psychiatry) is like a mechanic
repairing a car. Just as the mechanic restores the
car to its normal or proper functioning, so the doctor
in his treatment i2 supposed to be restoring a person
to his normal Bunctioning and righting the abnormalities in his performance. The success of this analogy
depends upon the applicability of the notion of function in both cases. There is little problem in
talking of the function of a car, since a car is a
human product and it is produced as something with a
function, as a means of transport. Furthermore, it,
is not difficult to see how the practice of physical
medicine may be viewed in terms of this analogy.

Although the body is not a human product and its /

The only thing in common [to the various states
thought of as ‘illness’] is that a value-judgement is expressed. In some sense, but not
always the same sense, ‘sick’ implies something
harmful, unwanted and of an inferior character.

If we want to get away from value-concepts and
value-judgements of this sort we have to look
for an empirical concept of what sickness is.

The concept of the average affords us such a
concept… The concept of the average is an
empirical concept of what concretely is.

[2]

These terms are taken from F C Redlich and D X
Freedman, The Theory and Practice of Psychiatry,
Basic Books Inc, NY, USA, 1966.

2

Jaspers, General Psychopathology, Hanchester
pp.7BO-I.

K

UP,

2

3

Cf. R M Hare, Freedom and Reason, OUP, 1963;
Philippa Foot, ‘Moral Beliefs’ in PAS 59, 1958-9
etc., discussion of words like ‘rude’ and ‘nigger’.

4

See also J Margolis, Psychotherapy and Morality,
Random House, 1966, esp. Ch.l for further
arguments.

him objectively by the society in which he and his
patient live.

function is not therefore, in that sense, man-given,
it often seems an uncontroversial matter to specify
the basic functions which the body should fulfil and
to decide whether it is functioning properly according to these standards. [5]

I have tried to present this argument with
sympathy – indeed I recognize the importance of the
considerations it raises, as will become apparent.

However, the argument clearly fails in its purpose;
namely to found the value-judgements implicit in
the concept of mental illness securely upon a basis
of objective fact. Just because the individual is
a part of society, and just because this society does
make real demands upon him, it does not therefore
follow that these demands are to be valued as
‘healthy’. What happens in the clinical account is
that the prevailing social conditions are taken as
fixed and given, and made the criterion of value
upon which the account of health and i IJness is
founded. What is valued is equated with what
exists – However, this does not found these values
on a factual basis; rather, it places a value upon
things as they in fact are. Such an attempt to base
the value-judgement implicit in the concepts of
health and illness upon the foundation of ‘what
exists’ (to use Jaspers’ phrase – quoted earlier) is
in fact a way of endorsing conventional values.

The problems of extending this mechanical
anlogy to the field of psychiatry are, however, much
greater; for we must now consider the question of
the function, not just of the body, but of the person.

This question can be interpreted more or less widely.

Interpreted most widely, it poses the classical
question of moral philosophy: what is the end of
life? – What is human fulfilment? I shall try to
show how later. However, those psychiatrists who
have adopted what I have called the ‘clinical
approach’ have typically interpreted this question
in the narrowest fashion. Thus, at the most basic
level, it seems possible to say that a person is
given a function by virtue of his particular role as
a member of society, and that his function is to
fulfil this role. Any person who cannot maintain a
social role fails according to these minimal standards,
and becomes a dyafunctional social unit, a ‘deviant’.

Clearly idealism isnot one of the virtues of this
account of the function of a person; however, a
certain vasic realism is. To live in a society one
must function in a certain fashion. Most people
have large demands made upon them by their social
lives – they must have the ability to feed, house,
clothe and protect themselves and so on with whatever
help is available to them. [6]

This relative account of mental illness is the
orthodox psychiatric view in its essentials, and
the symptoms listed in psychiatric textbooks are
abnormalities, in the sense I have just sketched, of
a more or less socially disabling kind. I have .

argued that such an account of mental illness implies
a value-judgement. However, just because the
psychiatrist imagines his account to be an ‘objective’

one, he is unaware of this value-judgement. In a
formal sense, therefore, a value-judgement is made;
but in a more substantial sense, no moral judgement
is exercised – that is to say, no moral thought is
exercised in arriving at this account of mental illness. It is notable in this context that the
psychiatric account of mental illness refers only to
gross and immediately observable behaviour and is
not framed in theoretical terms. That is to say,
it assumes that mental pathology is immediately·
apparent and given as obvious fact. The values
implied by the psychiatric account are unconscious
and unthought.

From this line of thought about the function of
a person arises the idea that mental illness is a
failure in a society; and illness thus defined, as
a form of social deviation, is a socially relative
concept. The society and the individual’s role within it are assumed to be normal (that is to say
‘healthy’: ‘normality’ is a common synonym for
‘health’ in psychiatry as in other areas of medicine).

Indeed, the prevailing social environment is made
the very criterion of normality, and the individual
is judged ill insofar as he fails to ‘adjust’ to it.

[7]
This clinical account of mental illness claims
to be an objective one because mental illness and
health are defined in terms of a person’s function,
and this appears to be a matter of objective fact.

A part, at least, of a person’s function – his social
role – seems to be objectively given to him by the
very fact of his social life. The social demands
upon the individual are real ones, which must be able
to meet for his social survival. If he cannot meet
these demands, he becomes socially incapacitated and
either he will seek ‘help’ or ‘help’ will be sought
for him, at first probably from his family and friends,
and ultimately perhaps from a psychiatrist. In this
way, the psychiatrist’s task appears to be given to
5

I have already made the point that health and
illness are practical concepts, necessitated by
the project of therapy. When the psychiatric account
of these concepts is viewed in relation to its
practical context of therapy, then the features
to which I have pointed – its relativism, its
endorsing of the prevailing social environment and
its idea of ‘value-free’ objectivity – become
comprehensible. For the way of thinking about
mental illness which I have just described is in
fact closely related to the practice of the individual therapist. [8] People usually (though not
always) come to, or are brought to, treatment because
they are unable to fulfil their social role. The
individual therapist sees the patient only,
abstracted from his social context. The therapist,
as therapist, can act directly on him alone; the
social environment from which the patient comes and
to which he must return cannot be altered, it must
be accepted as a given fact and the demands it makes
must be regarded as (in this sense) ‘objectively’ and
unalterably present. From the practical point of
view of individual therapy, therefore, the environment is assumed to be ‘normal’ and illness is considered as individual conditions of abnormality
against this background.

Although, n.b., this can provide only the most
minimal concept of physical health and illness.

6

This point is made at length by Peter Alexander,
‘Normality’ in Philosophy, Vol.48, No.184, April
1973; pp.137-l5l. However, he fails to see the
ideals involved in the concepts of mental health
and illness, the significance of psychoanalytic
work etc etc.

7

Of course it is not suggested, by those who think
of mental illness in this way, that all deviations
from social norms are mental illnesses. For
example, the factor of suffering is often mentioned
in the attempt to distinguish illness from other
forms of deviance; and mental illness is distinguished from physical illness, it is claimed, by
virtue of the fact that mental illness is indicated
by changes of mental functioning which have no
known physical cause. For this sort of argument,
see e.g. F Kraupl-Taylor, Psychopathology, Butterworths, 1966, Ch.l. Needless to say these lines
of demarcation are extremely imprecise at best.

The psychiatric account, then, is a purely
relative one; it is not based on a psychological or
any other theory of human activity but rather presents
8

3

I am using this word widely to include medical
psychiatrists, although I am aware that their
‘therapy’ often consists in nothing more than the
administration of sedatives and tranquilizers and
barely deserves the name.

‘mental illness’ as a purely individual condition,
obvious and immediately apparent against the background of a social environment which is presumed
(often unconsciously) to be ‘normal’o For all these
reasons the psychiatric account has little to offer
anyone seriously concerned about the human condition,
and it is increasingly being- revealed as-the
rationalization and justification for present social
and institutional means for dealing with the problem
of ‘mental illness’.

to the practical problem of ‘mental illness’.

This scepticism has been valuable, then, but its
significance is ultimately only negative since in
rejecting the concept of mental illness altogether
it also implicitly denies the existence of the
practical problems of the therapist. To see this it
is again necessary to remember that psychiatry is a
practical activity as well as a theory, and that the
concepts of mental health and illness are essentially
practical concepts that define the object and goals
of psychiatric practice. The implications of the
sceptical rejection of the concept of mental illness
are, therefore, that the practical problems tackled
by therapy are unreal ones and that the project of
therapy should be abandoned.

An awareness of these points has led to a
widespread general scepticism about the concept of
mental illness, which has been voiced by philosophers,
psychologists and sociologists. [9] Thus, for example,
R 0 Laing writes:

To this, the psychiatrist will reply [13], surely
with justification, that there is suffering of a nonphysical kind which the concept of mental illness is
supposed to describe and which is real suffering that
cannot be ignored for philosophical niceties. The
sceptical approach simply rejects orthodox psychiatric
thought and practice; but in doing so, it entirely
forgets the practical need for psychiatry: the real
suffering and misery to which psychiatry is intended
to be a response. This real suffering is the phenomenon which the concept of mental illness is supposed
to describe and specify. In tackling the practical
problems which this suffering presents, the therapist
is, or at least ought to be, helped and guided by a
theory. And for the theory to fulfil this practical
task, it must portray such suffering as illness,
over against health as a value.

The ’cause’ of ‘schizophrenia’ is to found by
the examination, not of the prospective
diagnosis alone, but of the whole social
context in which the psychiatric ceremonial
is being conducted.

[10]
Such an investigation reveals, according to Laing, that
There is no such ‘condition’ as ‘schizophrenia’,
but the label is a social fact and the social
fact a political event. This political event,
occurring in the civic order of society,
imposes definitions and consequences on the
labelled person. It is a social prescription
that rationalizes a set of social actions whereby
the labelled person is annexed by others, who
are legally sanctioned, medically empowered, and
morally obliged, to become responsible for the
person labelled. The person labelled is inaugurated not only into a role, but into a
career of patient …

The values of health and illness are the embodiment of the ideals of therapy, which are those of
medicine: the relief of suffering, the healing of
sickness. None of the arguments of the scepticism
I have been discussing actually dispute these ideals.

What this scepticism does argue is that this suffering has been conceived wrongly by psychiatric theory
and that orthodox psychiatric therapy 40es. little or
nothing to relieve and heal it. But because this
scpticism is merely negative towards the concept of
mental illness, it ends up by denying these ideals
altogether, without giving any argument,;’

[11]

Laing thus argues that mental illness is, in Szasz’s
words, a ‘myth’.

The basis for this scepticism is just that
relativism, the narrowly practical and technological
perspective and the covert conservatism which I have
already pointed to in the psychiatric identification
of ‘illness’ with lack of adjustment to the prevailing social environment. This scepticism leads to the
total rejection of the concept of mental illness as
useful to psychology. Sociologists like Goffman and
Scheff [12] in particular, have attempted to show
that the behaviour of mental patients can be understood solely in relation to the social institutions
in which they exist, without any reference to individual psychological considerations; and Laing, too,
has often written as if he accepted this view.

Whereas the psychiatric account asserts these
ideals blindly in an uncritical and mystified form,
this scepticism denies them equally blindly. Both
represent a failure to think through the practical
problem in critical and theoretical terms; and that
is to say, both represent a failure of serious moral
and psychological thought.

In the remainder of this paper my main purpose
will be to argue that psychoanalytic thought offers
the basis of an alternative account of the phenomenon
of ‘mental illness’ which is (at least potentially)
critical of the psychiatric account [14] and yet not
totally sceptical and in terms of which the
practical (i.e. moral and social) problems of ‘mental
illness’ may more adequately be seen and discussed.

Such scepticism has been polemically aimed at
current psychiatric practice, and it has been
valuable and illuminating as such. It has led to
much critical and important work concerning psychiatric procedures, and it has enabled people to break
from the psychiatric attitude – and such a break is
nothing less than an essential precondition for a
critical and scientific approach to psychology and
9

II

e.g. T S Szasz; R 0 Laing and his ex-co-workers;
E Goffman and T J Scheff, and also Sartre’s
critique implicit in Being and Nothingness,
Part I, Ch. 2, I Bad Faith’.

10

R 0

11

Ibid., p.lOO.

12

E. Goffman, Asylums, Penguin Books, 1968; and
T. J. Scheff, Being Mentally Ill, Weidenfeld and
Nicolson, London, 1966. See also the recent and
dramatic work of D. L. Rosenhan, ‘On Being Sane
in Insane Places’, Science, Vol.179, 19 January
1973, pp.250-8.

The significance of the contribution of psychoanalysis to the understanding of mental illness and
mental health, and its significance for moral and

Laing, The Politics of Experience, Penguin
Books, 1967, p.86.

4

13

See e.g. H. J. Eysenck, in his reply to Laing,
‘The Ethics of Psychotherapy’, Question 3,
January 1970, esp. p.3.

14

The qualification is important. The psychoanalytic
movement has reached a modus vivendi with
psychiatry, a division of labour in this area.

The effect of this at the theoretical level has
been that psychoanalysts have not tended to develop
the critical implications of their theory towards
orthodox medical psychiatry.

What set Freud on the path to psychoanalysis
was his hearing about a case treated by his colleague
and friend, Breuer – the case of Anna o. Breuer had
found that when she remembered and communicated
certain events associated in her mind with her symptoms, an alleviation of her symptoms ensued. Freud
became interested in this case and tried applying its
method in his own work. He was not a good hypnotist
and quickly abandoned the use of it when he discovered
that he could get his patients to recall the relevant
material without its help.

social thought are not well understood in this country,
particularly among moral philosophers. This is
partly because the positivistic tenor of so much
recent British philosophy has systematically blinded
it to what might be of value, not only in psychoanalysis, but in all social thought and moral thought.

It is hardly an exaggeration to say that the dominant tradition of moral philosophy in Britain has made
no concrete contribution to moral thought – and what
is even worse, it has not attempted to do so, but
has abdicated the task of substantial and conscious
moral thought (it is, of course, a substantial moral
ideology, but it is so unconsciously).

These memories and associations, however, were
not immediately present in his patients’ consciousness;
they had to be extracted against the resistance of
the patient. The observation of this resistance
the patient’s part led Freud to the ~pea that such
unconscious ideas (which were highly charged emotionally) are actually kept out of consciousness by a
force, which he called repression. Freud also
observed that when he asked the patient what he
remembered in connection with the first onset of his
symptom, the patient would sometimes say he could
remember nothing and that nothing occurred to him.

However, on pressing it would transpire that something
had passed through the patient’s mind, but that he
had deemed it irrelevant and had not mentioned it.

As a result of his investigations, Freud came to the
conclusion that such apparently irrelevant ideas
(‘free associations’) in fact occurred for a reason,
and that by trying to discover this reason he was in
fact pursuing his investigation of the nature of the
symptom; and that he could get the patient to
recognize and possibly even reconcile himself with
the repressed and unconscious ideas and desires
which were at the root of the symptom (its hidden
nature, its ‘latent content’). [17] Furthermore,
Freud discovered that these repressed ideas and
desires were commonly sexual, often of the most
tabooed form, and had a continuous history stretching
back to earliest infancy.

Thus it is not surprising that even where the
moral significance of psychoanalysis has been
discussed by these philosophers it has been misunderstood and misdescribed. For example, it is
often thought that psychoanalytic theory is a theory
only about ‘pathological’ or ‘abnormal’ behaviour,
and that its moral significance is confined to the
redefinition of our attitude to such behaviour. This
is only a fragment, and a relatively minor one, of
the truth.

An~nderstanding of psychoanalytic thought does,
of course, alter one’s attitude towards the ‘pathological’; but in so doing, it has profound and farreaching implications for one’s concept of ‘the
normal’. And it is in its relations about ‘normal’

everyday life that psychoanalysis has its major moral
significance. Laing is particularly clear on this:

The relevance of Freud to our time is largely
his insight and, to a very considerable extent,
his demonstration that the ordinary person is
a shrivelled, desiccated fragment of what a
person can be. [15]

Nevertheless, Freud did arrive at his psychological
conclusions through his investigation of mental
illness, and it was implicit in the theoretical
understanding of mental pathology which he evolved.

A very brief review of the history of Freud’s
discoveries may help to make this clear, and also
to emphasise that Freud did not arrive at this sort
of conclusion speculatively or by any form of merely
abstract reasoning.

In this way, and gradually over a long period of
time, Freud came to a theoretical understanding of
the nature of neurotic symptoms. According to this
theory, neurotic symptoms arise from a conflict between a person’s libidinal and pre-social instincts
and opposing repressive forces within the personality,
particularly the dictates of morality and conscience.

Although the idea of a conflict between desire and
morality was a common one before Freud, what Freud
showed was that if this conflict becomes too intense
and anxiety-provoking, the desire, the instinct, is
repressed – put out of mind and inhibited from active
expression. This is not the end of the story,
however, for the repression of the instinct does not
abolish it. It continues, as Freud puts it, ‘to
press for satisfaction’, which it achieves (in a
compromise form) in thought in the form of fantasy
and in action in the form of (neurotic) symptoms.

Freud was trained as a doctor, and he accepted
from this training the psychiatric and relative view
of mental illness which I described earlier. His
first patients were hysterics: that is to say,
patients with physical complaints, gross and obvious
symptoms which more or less incapacitated them in
their everyday lives. At the very outset of his
psychiatric career, Freud proceeded in the psychiatric
manner, to attempt to eradicate these symptoms. Freud
used hypnosis for this purpose, and (in the initial
cases reported in his first major psychological work,
Studies on Hysteria ) he describes how he would
attempt to command the disappearance of the patient’s
symptoms while the patient was hypnotized. This
method of treatment – literally ordering the symptoms
to disappear – is still used by some psychiatrists
today. However, Freud was not satisfied with this
procedure; his objections to it were both theoretical
and practical. Such a purely symptomatic treatment
offended against his very clear vision of proper
scientific procedure in medicine; it was a purely
pragmatic treatment which lacked a basis of theoretical understanding and justification. But furthermore,
judged by pragmatic criteria, it was ultimately
ineffective, as he learned from the case of Miss
Lucy R.:

This theory of neurosis not only altered Freud’s
understanding of, and therefore attitude to, ‘mental
illness’, it also changed his attitude to normality.

For the explanation which Freud had developed of the
psychiatric symptoms of hysteria applied equally to
a very extensive range of absolutely normal behaviour.

What Freud discovered was that a great deal of
‘normal’ behaviour in fact had exactly the same
structure as did neurotic symptoms. Again he discovered this through his analytic practice. For
example, he noticed that his patients frequently and
spontaneously recounted their dreams to him for no
apparent reason, as ‘free associations’. Instead of
brushing these aside as irrelevant to the treatment,
Freud investigated them, and this investigation led
to his richest work, The Interpretation of Dreams.

What had happened was precisely what is always
brought up against purely symotomatic treatment:

I had removed one symptom only for its place to
be taken by another. [16]

15

R 0 Laing, The Politics of Experience, p.22.

16

Freud, Studies on Hysteria, Standard Edition
Vo1.2, p.1l9.

Freud’s -theory of dreams portrays them as having
exactly the same structure of repression and compro-

17

5

Freud describes his initial discovery of these
facts in his account of ‘The Case of Elizabeth
von R.’ in Studies on Hysteria.

mise and wish-fulfilment as do neurotic symptoms.

And in addition to dreams, Freud argued that many
other absolutely ‘normal’ phenomena, like symptomatic
errors and slips of the tongue, certain very common
patterns of relationship which he called ‘transference’

and also traits of character, compulsive moralizing
and ‘the fear of God’, had the structure-of neurotic
symptoms.

repress a lot of his desires. And so the sort of
absolute definition of mental illness which is
suggested by psychoanalytic theory, so far from
making the social environment the criterion of
health, tends to be critical of prevailing social
conditions in the name of health. Repression and
therefore neurosis are absolutely normal and
universal features of our present lives.

Although, as I shall go into later, Freud did
not follow the implications of this theory through to
their end, this psychoanalytic account of neurotic
symptoms ultimately implies an approach to the
problems of mental illness which is distinct from
arid in contradiction to the orthodox psychiatric
account. On the basis of this psychoanalytic theory
it seems that what is characteristically pathological
about a mental sympton (i.e. what makes behaviour
symptomatic) is that it involves repression. [18]
Mental pathology is thus thought of as division
within the personality, and health is conceived as
the unity, integrity or wholeness of the person and
the absence of wasteful energy consuming self-division
and self-alienation. When the implications of
psychoanalytic theory for the concepts of mental
health and illness are interpreted in this way, the
goal of psychoanalytic practice is (in theory at
least) to heal the mind and person, in the original
sense of ‘to heal’ which is ‘to make-whole, to makeone’. Some of the formulations which Freud gives of
the aim of analysis emphasise this idea of health
as unity the corresponding healing function of
psychoanalysis. For example, he writes:

As Freud says:

It is impossible to overlook the extent to which
civilization is built up upon a renunciation of
instinct; how much it presupposes precisely the
non-satisfaction (by suppression, repression or
some other means?) of powerful instincts. This
‘cultural frustration’ dominates the large
field of social relationships between human
beings. [20]

The state of ‘normality’, which is the assumed
standard of health in the psychiatric account, is
revealed by this view as one of unconsciousness,
alienation and neurosis. Laing puts this view forcefully when he writes:

As adults, we have forgotten most of our
childhood, not only its content but its
flavour; as men of the world we hardly know
of the exitence of the inner world; we barely
remember our dreams, and make little sense of
them when we do; as for our bodies, we :retain
just sufficient proprioceptive sensations to
coordinate our movements and ensure the minimal
requirements for biosocial survival – to
register fatigue, signals for food, sex,
defaecation, sleep; beyond that, little or
nothing.

The aim of our efforts may be expressed in
various formulas – making conscious the unconscious, removing the repressions, filling
in the gaps in memory, they all amount to the
same thing. [19]

The conditions of alienation, of being asleep,
of being unconscious, of being out of one’s
mind, is the condition of the normal man.

It is clear that this represents a very
different way of thinking about the concept of mental
illness to the orthodox psychiatric account which I
described earlier. First of all, the concepts of
mental health and illness are now absolute and not
socially relative concepts. Mental illness is thought
of as an individual condition the distinguishing
criteria of which do not refer to the prevailing
social environment, but only to psychological processes
within the individual. This absolute account of mental illness does not therefore make the prevailing
environment into the criterion of normality and
health.

[21]
The standards of health and illness are here
applied according to criteria which are absolute:

which transcend the particular social envirionment of
the individual and which appeal to absolute values.

These criteria are not the result of direct and
immediate observation, but are the product of the
attempt to comprehend the phenomenon of normal andabnormal behaviour theoretically. Furthermore,
because they suggest that everyone is ‘ill’, their
practical implications for therapy are idealistic.

Qn the contrary: the absolute account of mental
illness is founded on an account of the function of
a person which is in conflict with that assumed by
the psychiatric account. I have already described
how the psychiatric account maintains that the
function of a person is to fulfil his basic role as
a member of society. The absolute account considers
the function of a person abstractly in-itself, and
not in relation to his particular social role. The
function of a person is thus thought of in terms of
self-realization as an integral person, lack of
alienation and wasteful self-repression, satisfaction
of his basic human nature (i.e. instincts), happiness
etc. And it is clear from what Freud writes that
the functions which these two accounts each suggest
are conflicting ones. In present conditions at least,
the social environment requires the individual to

18

More accurately, a symptom according to Freud
involves ‘the return of the repressed’ desire.

But the repressed wish always ‘returns’ and gains
expression, even if only in dream and fantasy.

These assertions need further discussion which
I cannot give here.

19

Freud, Introductory Lectures on Psycho-Analysis,
trans. Joan Riviere, AlIen &Unwin, 2nd Ed., 1929,
p.363.

Freud himself, however, never endorsed the
absolute account I have just outlined (even though
it is implicit in his theory), nor did he ultimately
acknowledge the ideals of health of the absolute
account nor its practical implications. This is
not to say that the practical implications of psychoanalytic theory were entirely ignored by Freud in
his work. Freud’s therapeutic work, in fact, did
change considerably in character with the development of his theoretical understanding as Reiff
observes:

In the beginning •.. though the patients Freud
treated did disclose doubts about what to do
with their lives .•. , there were always tangible
symptoms – a paralyzed leg, a handwashing
compulsion, impotence – by the resolution of
which one could certify the cure … [but
later] all experience is symptomatic ..•
People seek treatment because they sleep poorly,
or have headaches, or feel apathetic towards

6

20

Freud, Civilization and its Discontents, Hogarth
Press, revised ed., 1963, p.34.

21

R D Laing, The Politics of Experience, pp.22-3.

Freud’s account of mental health and illness is
contradictory, therefore, since it contains (implicitly
at least) both the accounts of these concepts which I
have outlined: the relative and the absolute.

loved ones, or because they are dissatisfied
with their lives. [22]

Nevertheless, as I have argued already, psychoanalytic theory implies that a vastly more extensive
range of phenomena are pathological than this.

However, in practice, patients do not come wishing to
be cured of such ‘normal’ neuroses, unless they are
causing them impairment in their everyday lives.

In conclusion now I want to argue that this
contradiction in Freud’s thought has an important
significance, and that we can learn from it; and
that it should not simply be dismissed as a sign of
mere confusion, as many contemporary British
philosophers are inclined to do when they come upon
contradictions. For there are reasons for Freud’s
thought being contradictory on this matter, there
are reasons for asserting both of these contradictory
accounts.

Freud is ultimately unwilling to divorce the
concepts of health and illness from the context of
therapy, and it is for purely practical reasons,
connected with therapy, that Freud is unwilling to
abandon the psychiatric and relative account of mental
illness, no matter how much it conflicts with his
psychoanalytic theory. Thus he says, for example:

Earlier I argued that there is a real basis to
the psychiatric account in the real problems that
confront the psychiatrist in his practice; and I
have also tried to show that the account of mental
illness given by psychoanalytic theory is a well
founded one. Both of these conclusions need to be
incorporated in an adequate account of mental illness,
and yet they seem to be opposed. For the struggle
between the social values of conformity embodied in
the psychiatric account and the apparently individual
values of fulfilment expressed through psychoanalytic
theory is a real one. [26]

The healthyman ••• is virtually a neurotic,
but the only symptom he seems capable of
developing is a dream. To be sure when you
subject his waking life to a critical investigation you discover something that contradicts
this specious conclusion; for this apparently
healthylife is pervaded by innumerable trivial
and practically unimportant symptom-formations.

The difference between nervous health and nervous
illness (neurosis) is narrowed down therefore to
a practical distinction, and is determined by
the practical result – how far the person
concerned remains capable of a sufficient degree
of capacity for enjoyment and active achievement.

Freud, when he did not just ignore it, thought
that this conflict was an eternal one, and in the
nature of things. His pessimism is notorious: he did
not believe that the individual can achieve fulfilment; neurosis, and the frustration it involves, were
for Freud, inevitable. And he saw no alternative to
a familiar and very real dilemma: either you are
spontaneously free and unrepressed, in which case
your society will suppress you; or you repress yourself and comply with the demands society makes upon
you.

[23]
In other words, according to psychoanalytic theory
everyone has neurotic symptoms, but it does not
follow that everyone is neurotic because the concept
of illness (unlike that of symptom) is a practical and
not a theoretical one. What Freud means by ‘practical’

here is shown in the following passage, where he
considers the question of whether everyone might be
neurotic. He writes:

But these are not the exclusive alternatives;
and the belief that they are, it seems to me,
derives from the fact that ultimately Fr~ud adopted
the individualistic perspective of the therapist the psychiatric account of mental illness, which
accepts the social environment as fixed and given.

However, Freud’s theory suggests that the social
environment itself may be pathological. The practical
implication which Freud drew from this was that a
therapist is needed with the authority to treat
society as a whole. This is hardly practical, but
surely a more realistic conclusion would be that
social and not merely individual change is necessary
if the therapeutic project of eliminating illness
and promoting health is to be achieved. What psychoanalysis reveals is the social and ultimately
political content in the concepts of mental health
and illness.

May we not be justified in reaching the diagnosis that, under the influence of cultural
forces, some civilizations, or some epochs of
civilization – possibly the whole of mankind have become ‘neurotic’? .•. -As regards the
therapeutic application of our knowledge, what
would be the use of the most correct analysis of
social neuroses, since no one possesses authority
to impose such a therapy upon the group? [24]

What Freud is saying here is that from the point of
view of individual therapy, the absolute account of
mental illness and health is an impractical and utopian one. And it is for this reason that he retains
the psychiatric and relative account as well.

Freud thus tries to hold on to both the psychiatric account and the psychoanalytic theory of neurosis
at the same time – but these two are in contradiction.

Freud never properly appreciated this contradiction in
his thought, and he tended to ignore the implications
of psychoanalytic theory and to dismiss them on the
narrowly practical grounds of the possibility of individual therapy when they came to his attention. [25]
22

P. Reiff, Freud: The Mind of the Moralist, Methuen,
1965, p.304.

23

Freud, Introductory Lectures, p.382.

24

Freud, Civilization and its Discontents, p.8l.

2S

He had other more sophisticated, although purely
speculative, ways of dealing with this contradiction as well; e.g. his talk of ‘qualities of
psychic energy bound in repression. To discuss
this matter adequately here would, however, take
me too far away from my central purpose, and I
will have to return to it elsewhere.

The problem of mental illness, then, is a social
and a political problem, but it is not just a social
or political problem it is also an immediate individual
problem, and this is stressed by the psychiatric
account and must not be forgotten either. The problem
of mental illness does not initially and immediately
arise as a social one. Immediately and initially it
confronts the practising psychiatrist as an individual
problem, in the shape of individual patients who are
suffering and need help. This immediate problem is a
real one, and people need the kind of help which
psychiatry is supposed, but in fact too seldom does,
provide. To simply say: th~ problem is really a
political one and will be solved only when a revolutionary social change has abolished the family,

26

7

I have used Freud’s dichotomy between social/
individual here, but I think it must be critically
rethought (along with other aspects of Freud’s
ideas on human nature and society) if the contradiction in Freud’s thought which I am discussing
is to be resolved satisfactorily.

exploitative work and the other alienating features
of our society – to say just this is to ignore the
immediate practical problem which confronts the
psychiatrist.

tion that such states, no matter how ‘normal’, are
states of suffering and ought to be a cause for
concern.

The concepts of mental illness and alienation
are moral concepts. Indeed they are among the most
important categories of contemporary moral thought;
but not in the sense of ‘morality’ in which many
contemporary British philosophers, to judge from
their examples (‘He ought to do X’, ‘y is right’,
‘z is good’ etc) appear to understand the term.

‘Mental illness’, as I have tried to show, is not a
merely evaluative concept: it is always embedded in
a ‘theory’ – a more or less systematically organized
point of view – by means of which man and his
activity are understood and assessed. The discussion
of this concept by recent British philosophers has,
however, often quite deliberately excluded any
critical consideration of psychology, social theory
etc. etc., with the result that it has tended to
uncritically endorse conventional attitudes by
reporting ‘ordinary usage’. This is a sure recipe
for producing ignorant apologetics. Anyone with a
faith in the possibiaity of philosophy being used as
a weapon of criticism (i.e. a radical philosophy)
will see the need to expose such ideological philosophy and replace it. For this, a concern with
psychology and social theory is essential. This is
not something ‘in addition’ to moral philosophy but
rather one of its essential aspects.

The immediate problem requires action, and it is
only through the attempt to deal with this immediate
problem, both practically and theoretically, that its
social and political dimension is revealed. In other
words, the problem is both individual and social; and
each of the accounts I have described in some way
ignores this.

Psychiatry must be a twofold activity which acts
. at ail individual and at a social level. The
psychiatrist must help the individual as he can, and
also fight those alienating and repressive social and
psychiatric institutions which frustrate this work.

The concepts of mental health and illness (or their
equivalents), critically and theoretically developed,
are valuable in guiding this task; and it is possible
to reject the blinkered conservatism of psychiatry
without ending in a total scepticism which has the
effect of ignoring the real problems. Perhaps the
concept of mental illness is too tainted by its
psychiatric’ use to be anything but misleading for
these purposes. The concept of alienation is a [27]
natural alternative, but unfortunately it has lost
almost all precise meaning through over-use in recent
years. Despite this, however, the concept of alienation has the advantage of suggesting a social aspect
to the condition it describes; and in addition to
this it has close historical associations with the
concept of mental illness in the 19th century
(‘alienism’ was a common word for psychiatry). But
most importantly, the term ‘alienation’ has evaluative
implications, and the use of it involves the recogni-

TWlS

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It has been used in this way by R D Laing in
The Politics of Experience.

See also J. Gabel,
La Fausse Conscience, Editions de Minuit, Paris,

1962.

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An International Revolutionary Theoretical Journal

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Winter1972

Articles:

RUSSELLJ ACOBY: Negative Psychoanalysis and Marxism
MARIO TRONTI: “Postscript” to Operai e Capitale
JEAN COHEN: Max Weber and the Dynamics of Domination
PIER ALDO ROV ATTI: Fetishism and Economic Categories
TRENT SCHROYER: On Marx’s Theory ofthe Crisis

/fIGHT IN F~ONT

-TWO J:’041..0WEJ) t.)P WiT ..

Notes:

SUSANBUCK-MORSS: TheDialecticofT.W.Adorno
DA VID HOFFMAN: Bukharin’s Theory of Equilibrium

< •

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Address all correspondence to: The Editor, Telos, Department of Sociology, Washington University, St. Louis. Missouri 63130, USA.

“As in religion we are warned to show our faith by
our works, so in philosophy by the same rule the
system should be judged by its fruits, and pronounced frivolous if it be barren, more especially
if, in place of fruits of grape and olive, it bears
thorns and briars of dispute and contention.”(Bacon)

University news
Professor of Peace
to be appointed

Y SAy He.’s CHANC.e!) SINCe ‘HOSe-PAys

TlIl’lr ;1£’5 ‘GA~NIIVt; rife ~oPES

~NO

lJ./rD PIlOdlt(j’t.l”ry TueoA.

~

A profE’ssor of pea~e, believed to
he the world’s first. is to be ap· ~~~:I:~~~~i’;I~~ir:~~db7a~~vre:I~:

pointed shortly. The Senate of Brad· tions.

ford Univ(‘rsity are completing
details for the appointment and it Oxford
is hoped the new professor will
start work next autumn, The chaIr
in peace studies is being established
with the help of a £75,000 grant
from the Society of Friends. which
was raised in only.nine weeks.

y .. ,

“The universities are the fountains of the civil
~ moral doctrine, from whence the preachers & the
gentry … sprinkle the same upon the people”
(Hobbes) .

pro vice· chancellor of the
university. Mr Robert McKinlay.

said that the new department would
investigate the ca;lses of conflict,
also the reasons for reaching agree·
ments. It would cover international

8

s has yet been
fessor of Class St

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