“I . . . committed sins of impurity, father,” confesses Stephen Dedalus, the character whose tumultuous coming of age is chronicled in James Joyce’s beautiful A Portrait of the Artist as a Young Man, during a moment of particular anguish.
Stephen confronts intense dread when he, after having visited brothels, learns from his religious leaders the torments awaiting sinners like him in hell. Stephen’s first thoughts are of overwhelming regret: “Could it be that he, Stephen Dedalus, had done those things? … Yes, he had done them, secretly, filthily, time after time, and, hardened in sinful impenitence, he had dared to wear the mask of holiness before the tabernacle itself while his soul within was a living mass of corruption.” [1, p. 137] Stephen’s agonies take on aspects of vivid delusion: “And the glimmering souls passed away, sustained and failing, merged in a moving breath. One soul was lost; a tiny soul: his. It flickered once and went out, forgotten, lost. The end: black cold void waste.” [1, p. 141] Stephen even experiences hallucinations, which soon give way to physical symptoms: “He sprang from the bed, the reeking odour pouring down his throat, clogging and revolting his entrails… He stumbled towards the window, groaning and almost fainting with sickness. At the washstand a convulsion seized him within; and, clasping his cold forehead wildly, he vomited profusely in agony.” [1, p. 138]
Stephen’s eventual confession ushers in a period of religious bliss, which, nonetheless, soon begins to develop characteristics of a neurotic obsession. “Gradually… he saw the whole world forming one vast symmetrical expression of God’s power and love. Life became a divine gift for every moment and sensation…” [1, p. 149] the narrator declares. Stephen begins dividing his day into periods of prayer, constantly saying rosaries and devoting each day of the weak to repentance for one of the respective seven deadly sins. Stephen also undertakes the repression of his senses, “striving also by constant mortification to undo the sinful past rather than to achieve a saintliness fraught with peril. Each of his senses was brought under a rigorous discipline.” [1, p. 150] Stephens penance soon acquires an obsessive character, as “[h]is confession became a channel for the escape of scrupulous and unrepented imperfections.” [1, p. 152] Stephen finally becomes miserable and isolated. “To merge his life in the common tide of other lives was harder for him than any fasting or prayer… His soul traversed a period of desolation in which the sacraments themselves seemed to have turned into dried up sources.” [1, p. 152]
Stephen later, happily, develops into a mature and profound man. These difficult periods constitute pivotal milestones in his growth. That’s why it could strike us as unsettling to entertain the prospect of attributing these thoughts to Stephen’s suffering of a mental illness.
Introduction. A philosophical problem posed by mental illness
Mental illnesses, such as depression and anxiety, are – especially in their more severe forms – debilitating ailments which hamper their sufferers’ successful functioning and diminish their quality of life. They’re also, at the same time, philosophically striking, in that they force us to differentiate, among a person’s thoughts, between those which are healthy and those which are not. This distinguishing act is philosophically significant for a number of reasons. Most fundamentally, it forces us to declare that thoughts deemed healthy must be kept, while those deemed unhealthy must be treated, and eventually, hopefully, eliminated. This selective treatment of our thoughts – which suggests for each thought, in short, either to “keep” or to “treat” – can contribute directly to our mental health and well being; this is provided, of course, that we place the line between healthy and unhealthy in an acceptable place. Various subtle factors make the ideal placement of this line a challenging matter.
The first factor concerns what I might call soundness. Most of us possess a natural belief that our thoughts are sound, reasonable, or accurate representations of the world around us. Mental illnesses might present certain challenges to convictions of this kind.
Patients suffering from psychosis or schizophrenia (especially those with insight) may experience thoughts that they perceive to be unsound or incorrect. In Schizophrenia and Other Psychotic Disorders, Tarrier and Taylor describe the delusions of one patient suffering from schizophrenia:
The voices also told Jim that his girlfriend was unfaithful, and he experienced “visions”, sent by the voices, of his girlfriend having sex with other men. He did not actually believe that his girlfriend was unfaithful, but he became very angry that the voices should make these accusations. 
Thoughts in this category do not present a philosophical problem with respect to soundness. Indeed, these thoughts appear unsound to the patient, and act against, and not for, his sense of soundness. We lose nothing in classifying them as unhealthy, and seeking to treat them.
A problem arises, on the other hand, when we contemplate classifying as unhealthy thoughts which do appear sound to their experiencer. We can imagine a patient suffering from anxiety saying, “My worries are sensible. They are necessary for me to remember and carry out my tasks.” Classifying this person’s worries as mere products of anxiety might undermine his sense that his thoughts are sound. A striking example is visible, also, in Stephen’s first set of trails described above. Stephen surely believes that his convictions of guilt are justified, and not mere results of mental illness.
A second factor is what I’ll call here willfulness. Most of the thoughts we experience seem to come from ourselves, in the sense that we produce them and preside over them. “’I’ not only exist but also ‘tell’ the brain what to focus on,”  write McHugh and Slavney in their seminal The Perspectives of Psychiatry. They continue, “Mental life is ‘willful’, a domain in which plans can be articulated, actions directed, and results appraised, criticized, or regretted.”  This sense of the willfulness of our mental life is precious, and the idea of mental illness might, once again, challenge it.
Psychotic patients may, once again, experience thoughts which appear explicitly to originate outside of the self. (This can also occur in isolated religious experiences; I will ignore these in this article.) Bruce Cohen, in Theory and Practice of Psychiatry, describes symptoms typical of a schizophrenic patient:
The patient believes that thoughts that are not his own literally are being inserted into his head. … [H]is current thoughts are being beamed into his head via a small transmitter, surreptitiously implanted in his brain while he was sleeping… 
Thoughts like these, again, do not pose a philosophical problem with respect to willfulness. These thoughts appear to originate outside the self to the patient, and they act against his sense of willfulness, and not for it. We lose nothing by classifying these thoughts as unhealthy and seeking to eliminate them.
On the other hand, we risk, in attributing to mental illness thoughts which one does perceive to be willful, undermining this person’s sense of wilfullness. A telling example might be found in a patient suffering from obsessive-compulsive disorder. “I desire to organize my things,” he might say. “These desires come from me alone.” To attribute this person’s thoughts to a foreign mental illness risks undermining his instinctive conviction that they come from him. A related example is visible, again, in Stephen’s second trial above. Stephen’s religious observances, he surely feels, are willful.
In short, thoughts which appear foreign pose no problems, as their targeting and elimination does not threaten the patient’s sense of mental integrity. Thoughts which do appear sound and willful to the patient, on the other hand — and most mental illnesses create thoughts of this sort — create philosophical problems. The problem is a tension between our wish to identify and treat unhealthy thoughts, on the one hand, and, on the other, our desire to preserve, when possible, one’s sense that his thoughts are sound and willful.
This article does not discuss the task of determining which thoughts are unhealthy. I leave this task (which, incidentally, features both technical and philosophical aspects) to the experts. I only investigate the potential consequences of such a determination on one’s sense of mental integrity.
If we view things in the right way, these apparent consequences may dissolve to some degree.
The successive levels of the “self”
Though soundness and willfulness are essential features of the way we view our own minds, the notion that our thoughts could be otherwise has a long history. Freud evidently developed the notion that the self, or ego, is but a small part of our mind; the remaining pieces, like the id, exert upon us forces which originate outside of the jurisdiction of the self. Christian notions of the devil’s influence on us in our daily lives give expression, arguably, to this same very idea, namely that whereby certain of our thoughts are neither sound nor willful. This phenomenon incidentally appears in Portrait, when Stephen notes that “Frequent and violent temptations were a proof that the citadel of the soul had not fallen and that the devil raged to make it fall.” (153) Among those who refrain from using drugs and alcohol, finally, one standard explanation for their abstinence is that “I don’t like feeling like I’m not in control.” Mental illness, it seems, introduces one further sense in which a thought one experiences might be said to come from outside of his self.
Implicit in all of the above examples, of course, is the strange fact that we feel that certain of our thoughts correspond to our selves while others do not. This idea is familiar to us, in fact; many of us have perhaps heard statements like “I don’t feel like myself these days” or “I want to feel like my old self again”. These utterances seem paradoxical on their face: If the self were that entity which experiences feelings and produces thoughts, then how could this entity sense that certain feelings and thoughts are distinct from it? The answer, of course, is that the “self” – whatever it might be – is not connected equally to all of our thoughts and feelings, but particularly to some. A naïve model could have it that the self, the seat of consciousness, inhabits the mind, which furnishes, in turn, additional faculties like memory, attention, and perception. Statements like “I don’t feel like my self” reflect a problem in these latter faculties.
This model too runs into problems. Even though perception, say, is part of the “brain” and not the “mind” in the model above, perception often can, in certain ways, feel like part of the self. A feeling that the perceived world is dull and flat, for example – often present in depression – does involve the self, in some way, in the sense that one could just as well say “My perception feels dull and flat” as “I feel dull and flat”. This is true of memory and attention too. Indeed, these all are perhaps better regarded as “lower-order” parts of the self.
I propose a more refined model. (This is, of course, just a model – intended to describe subjective psychological experience – and I do not claim that it reflects brain structure.) The gap between brain and mind may be spanned by a sequence of “lower- and higher- order selves”. The lower-order selves are those more directly tied to physiologic function. As the mind and consciousness emerge from the activity of the brain, successively higher-order selves appear. The highest-order selves are those which perform reflective functions like the establishment of values, plans, and identity.
This model serves to resolve several apparent paradoxes. Statements like “I don’t feel like myself”, discussed above, indicate that lower-order selves are failing to operate compatibly with higher-order ones. Similarly, this model can also explain the sense in which one might feel that certain thoughts and feelings – like anxious or obsessive thoughts – are unwelcome intrusions even as they do appear to form part of the conscious and willful self. Here, lower-order, and not higher-order, parts of the self are involved. On the other hand, deeper psychological afflictions of the sort perhaps best treated by psychotherapy – such as emotional challenges or trauma – are ailments of the higher-order selves.
Applications of the “stratified self” to examples
Previously, I identified a tension in which the desire to identify and treat mental illnesses may conflict with one’s sense according to which his thoughts are sound and willful. The stratification of the self I’ve suggested above will refine this picture. In each case, some tension will persist; this tension, on the other hand, will adopt a number of more subtle, and less threatening, forms. I’ll explore how the model treats a number of examples.
In An Acceptance-Based Behavioral Therapy for Generalized Anxiety Disorder, Roemer and Orsillo describe a case study:
Héctor was a 24-year-old Latino man who presented for treatment after being placed on academic probation. Although Héctor had an extremely strong academic record as an undergraduate, he was struggling to keep up with the course demands in his first semester of medical school. Héctor initially sought treatment from his primary care provider for a wide variety of stress-related symptoms, including frequent headaches, muscle tension, and gastrointestinal distress. However, she urged him to seek therapy for what she believed to be an anxiety disorder. 
The authors describe Héctor’s worried thoughts:
[Héctor] described a long history of worry that started in elementary school. His worry focused centrally on academic demands. He reported worrying constantly about the quality of his work, the sufficiency of his knowledge, and his ability to meet his, and others, academic-related expectations.
The authors go on to describe additional worries about Héctor’s mother’s health, his nephews’ development, and more.
Our model adds interesting perspective to Héctor’s case. We may plausibly suppose that Héctor’s worries appear, to himself, as both sound and willful – as necessary reactions to his circumstances – and we may wonder, as before, whether, by attributing these worries to a harmful anxiety disorder, we could undermine Héctor’s sense of trust in his own thoughts.
In short, undermining Héctor’s sense of self is a plausible consequence here – but a less harmful one, in this case, than we are initially tempted to expect. Indeed, we may argue that the levels of Héctor’s self which are afflicted by his anxiety disorder are very low ones – close to the level of his physiology – and that, while these levels stand to be criticized, his higher-order, and more reflective, selves may proceed intact. Héctor’s low-order selves fail to produce sound and willful thoughts; his physiological stress response is perhaps overly active, and should be treated, possibly with medication. Héctor’s identity and values, on the other hand, are healthy and intact. These higher-order selves contribute more to Héctor’s sense of self and identity. We criticize, in other words, parts of Héctor’s self which are relatively less attached to his identity.
This case exhibits a more general consequence of the model we’ve described. We may identify a certain class of mental disorders characterized by the fact that certain apparently sound and willful thoughts are, while unhealthy, attached to lower-order selves. Though these selves must be criticized – and the patient’s sense of self might be undermined to some degree – the selves are, thankfully, lower-order, and the risk to the patient’s sense of mental integrity is not as great as it initially seems. For this class of disorders, our model permits us to resolve, at least to some degree, the tension suggested above.
Another sort of mental disorder is presented in a case study in Monson, Resick, and Rizvi’s Posttraumatic Stress Disorder.
“Tom” is a 23-year-old, single, white male who presented for treatment approximately 1 year after a traumatic event that occurred during his military service in Iraq. Tom received [Cognitive Processing Therapy] while on active duty in the Army. 
Tom grew up in a difficult family with a frequently absent alcoholic father. When Tom was an adolescent, he witnessed his best friend commit suicide by a gunshot to the head; later, Tom’s brother died in an automobile accident. Before his deployment, Tom was drinking as much as a 24-pack of beer a day, and using marijuana. 
More significantly, during his military service, Tom played a role in the shooting death of a pregnant woman and a child:
It was dark outside. A car began approaching the checkpoint, and officers on the ground signaled for the car to stop. The car did not stop in spite of these warnings. It continued to approach the control point… Per protocol, Tom fired a warning shot to stop the approaching car, but the car continued to the control point. About 25 yards from the control point gate, Tom and at least one other soldier fired upon the car several times.
After a brief period of disorientation, a crying man with clothes soaked with blood emerged from the car with his hands in the air. The man quickly fell to his knees, with his hands and head resting on the road. Tom could hear the man sobbing. According to Tom, the sobs were guttural and full of despair. Tom looked over to find in the pedestrian seat a dead woman who was apparently pregnant. A small child in the backseat was also dead. 
Tom goes on to describe pervasive and difficult feelings of guilt, mistrust, and anxiety.
It’s reasonable to suggest that Tom’s mental challenges are of a different sort than Héctor’s. Tom’s challenges reside in his highest-order, most reflective selves; Tom seeks, in the face of his actions, to make sense of his feelings of guilt and responsibility.
I was friggin’ stupid and made a bad decision. I killed an innocent family, without thinking. I murdered a man’s wife and child… I feel like I don’t deserve to live, let alone have a wife and child on the way. Why should I be happy when that man was riddled with despair, and that innocent woman, child, and unborn child died? 
A more appropriate response in this case might be therapy. In fact, Tom does enter therapy, where he undergoes Cognitive Processing Therapy. Tom and his therapist discuss how Tom can better regard and cognitively process his actions. The article’s authors record eventual substantial improvements in Tom’s mental health.
In Tom’s case, we again wonder whether the assessment that Tom’s cognitive processing habits are unhealthy might undermine his belief in the soundness and willfulness of his own thoughts. He surely considers his reactions to his traumas to be sound and willful, after all.
Once again, the stratification of the self cannot offer a complete solution here, and yet we get a consolation. In this case, elements of Tom’s deepest self are being declared unhealthy, and they must change if Tom is to improve. On the other hand, the process of healing these elements promises deep philosophical reward, and a life which is more philosophically sound, not to mention more pleasant. As Tom undergoes therapy, his most reflective selves will themselves change as the therapy progresses. This will be a period of philosophical growth. Though it will deny his thoughts’ soundness and willfulness, it will do so in a way which respects Tom’s intelligence.
This leads to the identification of another class of disorders, characterized by troubledness in a patient’s higher-order selves. Though the identification of the troubledness of these selves necessitates their change, this change is of a philosophical sort, and represents an opportunity for the patient’s growth.
We can summarize the two classes of disorders we’ve identified as follows. In the first, the diagnosis threatens to undermine the patient’s confidence, but in lower-order parts of his self. In the second, the diagnosis concerns higher-order parts of the patient’s self, but need not undermine his confidence in them.
The case of young Stephen Dedalus, above, offers a last example in which all of these principles become apparent. Whether Stephen’s thoughts are symptomatic of mental illnesses is not clear. Before we consider deciding that they are, though, we should recognize that multiple layers of Stephen’s self are at play. On the one hand, Stephen exhibits repetitive and compulsive anxious thoughts. If we were to declare these as unhealthy, we would offer Stephen relief from them, while threatening, thankfully, only lower-order parts of his self. On the other hand, Stephen expresses deep and distressing crises of meaning. If we were to declare these thoughts as unhealthy, we would do so with the knowledge that, at least, the resolutions of these crises have the potential to shape and improve the philosophical course of Stephen’s life.
Both of these ultimately take place.
- James Joyce. A Portrait of the Artist as a Young Man
- Barlow, ed. Clinical Handbook of Psychological Disorders: Fifth Edition
- McHugh, Slavney. The Perspectives of Psychiatry
- Bruce J. Cohen. Theory and Practice of Psychiatry