Of mental health and medical models

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.

Cross-posted at Love of All Wisdom.

One Reply to “Of mental health and medical models”

  1. A very timeous post, Amod! and interesting, given the evidence that Facebook and Instagram are bad for the mental health of young people. But coming from philosophy rather than health sciences, you miss some of the context. The medical model was formally established by Galen, in a famous demonstration witnessed by Stoic and Peripatetic philosophers, where he showed by surgical incision that voluntary movement in animals derives from the brain, not the heart.

    So the medical model is an animal model, assuming a rational soul shared with higher mammals. In the nineteenth century, when doctors still read Galen, that sense of rational was referred to logic, taken to reflect the “laws of thought”: thus mental health came to mean simply having your faculties intact. And the psychiatry that followed defined the major mental disorders as *organic conditions.

    There lies the philosophical problem, for a free and moraly responsible spirit or subject canot be comprehended in such physical terms; yet such a spirit as individual can’t be located in experience. Now Galen had from the herbalist (!) Dioscurides already a fourfold taxonomy of diseases, mapped onto the qualities of hot, cold, wet and dry; from earlier Hippocratic works, notably On Human Nature; with the interest in causal demonstration, and the fourfold functional division into “diagnosis, etiology, prognosis and treatment”.

    Importantly, ALL of that is definitely posterior to the Buddha and the Four Noble Truths., contemporary with the Charaka Saṁhitā. And informs also the Four Medical Tantras in the Tibetan tradition. BUT one key element eascapes, with the term “paramanu, which appears in the Abhidharma-hrdaya (Heart of Abhidharma) from Bactria (!). That brings in the notions of atoms and molecules, which Galen rejected, from the ancient traditions of Asclepius, Divine Physicians, spagyric alchemy (dyes, poisons, antidotes). And gives us also the drugs of modern psychiatry.

    There we touch on the old question of the Buddha’s teachers. I don’t see him listening to Sāṅkhya or Vaiśeṣika philosophers; but we do hear that he left his royal household seeking some cure for sickness and death awaiting us all. Not philosophers but professional teachers serving medicine and law, speak to that need. And when they came again to the texts that gathered around and after the Buddha, reaching out to Bactria, later East Turkestan, as the mecca of the Silk Road, where experts again came to the Second International Conference recorded in the Four Medical Tantras.

    There, importantly, a taxonomy of nine degrees of heat in disorder upsets the fourfold symmetry of Dioscurides and Galen, revealing the spectrum of inflammation, as we now see it, just the current focus of interest in systemic medicine: that nagging, relentless hunger of hurt, which subverts everything the body can bring to healing.

    And something quintessinal of adolescence as the heat of awakening to an adult body, which leaves us all scrambling to catch up with the complexity of it all. If the norm is now referred, not to laws of thought, but Photoshop fantasies on Instagram, that is a recipe for feelings of inadequacy, as plague adolescents. But isn’t that problem also familiar from nama-rūpa, name and form endveloping all our thoughts with empty idealizations of meaning?

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