Is Mental Illness a Choice?

The way that we understand “mental illness” has an enormous impact on how we view individuals suffering from psychological and emotional conditions.  Do we believe these individuals to be suffering from a “disease” beyond their control or from normal responses to abnormal situations?  There is much debate over whether or not psychological and emotional conditions such as depression, anxiety, or personality disorders exist at all.  For those of us immersed in the field of mental health, it may be possible to forget to even question the validity of these “disorders.”

Rational Choice Theory of Neurosis (RCTN) posits that individuals “consciously and deliberately adopt neurotic disorders when confronted with intolerable levels of stress” (Rofe, 2010).  The idea is that through complex cognitive processes of unawareness, we forget our own self-involvement with symptoms.  RCTN assumes that when individuals are faced with intolerable levels of stress, ways of responding to the stress become very limited.

Choice theory tells us that individuals essentially “choose” symptoms to deal with stress, because this is the best way the individual can come up with at the time to deal with the situation.  Symptoms function as distractions from the original source of stress, which alleviates some of the emotional distress being experienced.  How does the idea that we essentially choose symptoms to deal with stress sit with you?  How does it change the way you view mental illness to think of symptoms (e.g., anxiety, depression, substance abuse) as the best choices we can come up with at the time to alleviate distress?  While some of these symptoms may act as temporary distractions from the core problem, they often make matters worse.

Much of what defines the way the public thinks of mental illness originates in the disorders listed in the Diagnostic and Statistical Manual of Mental Disorders. This is the tool that psychologists and other mental health professionals use to diagnose mental disorders.  While this manual is currently in its fourth edition, the fifth edition will be coming out in May 2013.  To reiterate the changing picture of “mental illness,” consider the way that multiple disorders in this manual are being drastically revised, or eliminated altogether, in the upcoming edition.

What thoughts and feelings come up for you when considering what “mental illness” really is?  Do you find yourself feeling defensive, curious, or agreeable to the suggestion that what we consider to be “mental illness” is actually a choice (albeit a maladaptive one)?  We all have different ideas about what mental illness is and is not; these ideas are usually a composite of a lifetime of personal experiences and acquired knowledge.  How has your own personal experience impacted the way you conceptualize mental illness?

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Rofe, Y. (2010). The rational-choice theory of neurosis: Unawareness and an integrated therapeutic approach. Journal of Psychotherapy Integration, 20(2), 152-202.

Featured image: Theyyam Explored !! by Ajith / CC BY-SA 2.0


About Laura K. Schenck, Ph.D., LPC

I am a Licensed Professional Counselor (LPC) with a Ph.D. in Counseling Psychology from the University of Northern Colorado. Some of my academic interests include: Dialectical Behavior Therapy, mindfulness, stress reduction, work/life balance, mood disorders, identity development, supervision & training, and self-care.


  1. James on May 31, 2011 at 10:34 am

    While, in large part, I am agreeable to the idea that mental illness is a choice, it also strikes me that it is obviously not so simple.

    I have long thought that many “mental illnesses” are the simply result of a lack of life skills. When an individual hasn’t developed any given life skill to the point where he can effectively deal with any given stress in a positive manner, he will choose to deal with it in a maladaptive manner, and the symptoms of his underdeveloped life skill will appear in the form of a metal illness. However, in most instances, this choice is not a conscious choice, which renders the use of the word “choice” problematic, as we tend to think of a choice as being something about which we are conscious.

    In addition, I find it impossible to believe that all mental illnesses can be chalked up to maladaptive choices. It strikes me that many mental illnesses are the result of things that the individual has little to no control over whatsoever. Many factors, from genetic deficiencies to toxic biochemistry, can be factors in mental illness. For example, it is difficult for me to believe that an individual plagued by schizophrenia is making the choice (conscious or otherwise) to cope with stress through the use of auditory hallucinations.

    Regardless, whether any given mental illness is a choice or not, it remains a mental illness… As the choice to cope with stress in a manner that is harmful to oneself demonstrates mental illness. As such, thinking about mental illness as a choice would serve to inform the manner in which one would/should approach a mental illness, but it does not negate the presence of the mental illness.

    • Laura on June 4, 2011 at 7:35 pm

      James – I think you’re quite right that the idea of whether or not mental illness is a choice is not so simple.

      I agree with you to a large extent that a great deal of emotional and psychological anguish is the result of a lack of life skills. When individuals are unable to meet their basic needs (which includes closeness to other people), then they suffer. Many people simply do not know how to go about meeting these basic needs, and much of the disturbed/distressed behavior that we see in the “mentally ill” is simply these peoples’ best attempts at getting their needs met. I tend to believe that even when people are acting in destructive/self-destructive ways, they are making the best choices that they can come up with at that moment. Even someone acting out in a violent rage is often doing so because they cannot see a better choice in that moment.

      I can see how the word “choice” becomes problematic when one considers the assumed conscious nature to “choices.” William Glasser, psychiatrist and creator of Reality Therapy, views all behaviors as choices, even the supposedly unconscious behaviors (e.g., obsessive-compulsive behaviors and auditory hallucinations). He sees individuals (even those who experience hallucinations, such as hearing voices) as choosing their symptoms. It is the basic idea of deriving some type of benefit from the symptom, and when that need is fulfilled in another (i.e., more responsible) way, then the individual no longer has need of the symptom. It then goes away when it is no longer needed.

      But yes, regardless of whether or not mental illness is a choice, it remains quite problematic for the individual and those around him. If it is helpful for the individual who is suffering to reframe their distress as something they are choosing, then by all means I think this should be the therapeutic approach to treatment. For many people, simply having a concerned person in their lives (e.g., their therapist) ask them, “Why do you think you are choosing that behavior?” can be a real awakening.

      Thank you for your thoughtful comment!

  2. n on August 26, 2011 at 12:49 pm

    What about people who have hallucinations and hear voices? Is that a choice? How do you choose to have hallucinations? How is mental illness any different than autism or learning disabilities? They’re all mental disorders. Don’t be so narrow minded. This isn’t the 1950s. Mental illness is difficult enough without your judgment.

    • Laura on August 26, 2011 at 1:32 pm

      N – I understand that the topics of mental illness and hallucinations are sensitive subjects. The idea of mental illness as a “myth” is highly controversial, and my thoughts on the subject are intended only to pose questions and stimulate discussion, not to judge. I work with clients who experience a wide variety of mental issues and supporting them in understanding their experiences and alleviating their suffering is very important to me.

      I am open-minded to all ideas grounded in research or with strong theoretical underpinnings. The specific idea of mental illness as a “myth” can be explored further in an article published in the American Psychologist by Thomas Szasz many years ago: The Myth of Mental Illness.

      Modern scientific research has provided us with an incredible body of knowledge related to the neuroanatomy of auditory hallucinations. Scientists in the Netherlands have recently discovered that particular regions of the left temporal lobe are more active during auditory hallucinations. They ascertained that the brain is essentially “tricked” into believing that a voice is coming from an outside/other source, but in reality the voice is being produced within the person’s own brain.

      The Rational Choice Theory of Neurosis is a much more current discussion on the topic of choice & mental illness than is Thomas Szasz’s article from the 1960’s.

      No matter what the true origins of any form of mental illness or emotional distress are (e.g., choice, brain dysfunction, family/childhood origins, trauma, etc.), all forms of mental illness or distress cause great suffering to people. People respond to different approaches to treatment in very different ways. Some forms of therapeutic interventions are more helpful to some individuals than others. What matters is finding an approach to treatment that is effective in reducing suffering.

      Thank you for your comment and for generating this discussion.

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