The Myth of Mental Illness

The February 1960 issue of The American Psychologist featured a revolutionary article, one that was deliberately excluded from every major psychiatric journal at the time, written by Thomas S. Szasz, M.D. The title of the article was “The Myth of Mental Illness.” This piece began with the following statement: “My aim in this essay is to raise the question, ‘Is there such a thing as mental illness?’ and to argue that there is not.”

At first glance such a statement may sound absurd, but Szasz later published an entire book on the same topic, and with the same title, The Myth of Mental Illness. More than half a century later, Szasz wrote a new preface to his book observing that, “In the 1950′s, when I wrote The Myth of Mental Illness, the notion that it is the responsibility of the federal government to provide ‘health care’ to the American people had not yet entered the national consciousness.”  Today however, the notion that it is the responsibility of the federal government to provide ‘health care’ is so engrained in the national consciousness that to suggest otherwise, at least in some circles, borders on political heresy.  How did this happen?  And is mental illness really a myth?  Is there really no such a thing as mental illness?

Szasz went on to explain in the new preface to his book that “Fifty years ago, the question ‘What is mental illness?’ was of interest to the general public as well as to philosophers, sociologists, and medical professionals.  This is no longer the case. The question has been answered – ‘dismissed’ would be more accurate – by the holders of political power: representing the State, they decree that ‘mental illness is a disease like any other.’  Political power and professional self-interest unite in turning a false belief into a ‘lying fact.’”

Although Szasz was a keen observer and a skillful social critic, perhaps a portion of the previous statement deserves further examination.  Szasz claimed that the question ‘What is mental illness?’ was no longer of interest to the general public, philosophers, sociologists, and medical professionals, but he made this claim based on the reception of his work among his critics.  Although the question ‘What is mental illness?’ has often been dismissed, as Szasz argues, it is has not been satisfactorily answered, and is therefore still worthy of discussion.  In fact, whether or not it can be satisfactorily answered, the question may be of more interest now than it ever was before.

In the new preface to his book The Myth of Mental Illness, Szasz continued, “The claim that ‘mental illnesses are diagnosable disorders of the brain’ is not based on scientific research; it is a lie, an error, or a naive revival of the somatic premise of the long-discredited humoral theory of disease.  My claim that mental illnesses are fictitious illnesses is also not based on scientific research; it rests upon the materialist-scientific definition of illness as a pathological alteration of cells, tissues, and organs.  If we accept this scientific definition of disease, then it follows that mental illness is a metaphor, and that asserting that view is asserting an analytic truth, not subject to empirical falsification.”

If the notion of ‘mental illness’ is not based upon the scientific definition of disease, and is merely a metaphor, what can doctors possibly mean by diagnosing patients with ‘mental illness’?  Since ‘mental illness’ is not really a scientific or a medical phenomenon, what can it possibly be?  Szasz explained: “I insisted that mental hospitals are like prisons, not hospitals; that involuntary mental hospitalization is a type of imprisonment, not medical care; and that coercive psychiatrists function as judges and jailers, not healers.  I suggested that we view and understand ‘mental illnesses’ and psychiatric responses to them as matters of law and rhetoric, not matters of medicine or science.”

Szasz also insisted that his thesis was not a fresh insight, nor was it a new discovery. The reason why such arguments seemed new was, as Szasz explained, “because we have replaced the old religious-humanistic perspective on the tragic nature of life with a modern dehumanized pseudomedical perspective on it.”  In other words, the notion of mental illness grew out of the “secularization of everyday life” and the “medicalization of the soul and of suffering of all kinds.”

Disagree if you will, but not without first understanding the substance of Szasz’ thesis.  In essence, Szasz was arguing that “the behaviors we call ‘mental illness’ and to which we attach the hundreds of derogatory labels in our lexicon of lunacy are not medical diseases.”  What are they?  “They are the products of the medicalization of disturbing or disturbed behaviors- that is, of the observer’s construction and definition of the behavior of the persons he observes as medically disabled individuals needing treatment.  This cultural transformation is driven mainly by the modern therapeutic ideology that has replaced the old theological worldview, and the political and professional interests it sets in motion.”

In the body of his book The Myth of Mental Illness, Szasz took into consideration the economic, moral, political, social and medical forces that played a role in shaping modern psychiatry.  In doing so, he traced the invention of “mental illness” to Charcot and the problem of hysteria.  Before Charcot, illness was primarily understood to be a bodily disorder resulting from visible physical causes.   As dissection and anatomy began to form the basis of medical science, psychiatry took a different route: “It is important to understand clearly,” wrote Szasz in the introduction to The Myth of Mental Illness, “that modern psychiatry – and the identification of new psychiatric diseases – began not by identifying such diseases by means of the established methods of pathology, but by creating a new criterion of what constitutes disease: to the established criterion of detectable alteration of bodily structure was now added the fresh criterion of alteration of bodily function; and, as the former was detected by observing the patient’s body, so the latter was detected by observing his behavior… Thus, whereas in modern medicine new diseases were discovered, in modern psychiatry they were invented.”

The invention of new functional illnesses, beginning with hysteria, has multiplied and continues to multiply indefinitely, filling volumes, such as the ominous (and opprobrious) Diagnostic and Statistical Manual of Mental Illnesses.   Such inventions, to the detriment of many, have become synonymous with, or at least parallel to, conventionally discovered biological illnesses.  The result is that, absent fixed criteria and empirical evidence, “any phenomenon studied by the observer may be defined as a disease.”

To this last point, there are innumerable examples of “diseases” that have been invented in order to control or subdue particular groups or individuals (see, for example, Drapetomania or Oppositional Defiant Disorder, ODD).  This is not to say that mental or emotional suffering is not real, but that, in many cases, the psychiatric labels applied to such suffering can range from seemingly arbitrary to blatantly absurd.  Szasz’ acute insight was that the roots of modern psychiatry, whose primary figures include Charcot and Freud, are planted deep in the soil of a dehumanized and objectified view of patients.  Thus, as Szasz demonstrated in his book, “Charcot and the other physicians who worked there functioned as rulers vis- à-vis their subjects.  Instead of intimacy and trust, their relationship to each other was based on fear, awe, and deception.”  In sum, Charcot and his acolytes made it easier for sufferers to be labeled as sick, and therefore easier for them to be subjected to coercive “treatment.”

Szasz then addressed the social contexts of medical practice, in which he discerned the social harm that arises from the therapeutic state, while distinguishing between private practice and charity practice.  Szasz honed in on the coercive nature of the therapeutic state, and psychiatry’s role within that state: “In short, the private, two-person therapeutic situation maximizes mutuality and cooperation in the relationship between the participants; whereas the public, multiperson therapeutic situation maximizes deception and coercion in the relationship among them.  In Western institutional psychiatry as well as in Soviet medicine, physicians and patients can thus force one another to do things they do not want to do: for example, physicians can coerce patients by ‘certifying’ them as insane, or by certifying or refusing to certify that they are genuinely ill; and patients, in retaliation as it were, can sue physicians for illegally imprisoning them, or can denounce them to the authorities on a wide variety of charges.”

Szasz also recognized that so-called “medical care” can be used as a form of social and political control: “It is evident that anything that affects large numbers of people and over which the government or the state has control may be used as a form of social control.  In the United States, for example, taxation may be used to encourage or inhibit the consumption of certain goods.  In the Soviet Union, medicine may be used to control personal conduct and mold society in a desired direction.  Moreover, just as taxation is also used as a method of social control in Russia, so medicine is also used in this way in the United States… Both systems are thus admirably suited for ‘gently’ keeping ‘in line’ the discontented and dissenting members or groups of society.”  If this was true when Szasz published his book, could it also be true today?

In chapters four and five of The Myth of Mental Illness, Szasz delved deeper into the history of hysteria and Freud’s impact upon the field of psychiatry.  He traced the search for the biological and physical causes of so-called psychopathological phenomena to the investigator’s “craving for prestige and power” rather than his desire for “understanding and clarity.”  By adopting the medical model of illness, psychiatrists were enabled to “share in the prestige and power of the physician.” In chapter six, Szasz confronted the contemporary views of hysteria and mental illness, concluding that a gulf exists between the “psychologically minded psychiatrist” (of which Szasz was one) and his “organicist colleague.”

Having proffered his criticism of psychiatry, Szasz proceeded to lay out his own analysis of behavior and theories of personal conduct.  Suffice it to say that if psychiatry establishes false premises for understanding ‘mental illness,’ Szasz may have felt constrained to elucidate a theory to take its place.  Rather than fiddling with Szasz’ substitute theories, let us understand the conclusions that Szasz himself reached from his research, namely, that the customary definitions of psychiatry are worthless and misleading, and that mental illness, as commonly understood, is a myth.  At the end of The Myth of Mental Illness, Szasz included a helpful summary of his argument:

“1. Strictly speaking, disease or illness can affect only the body; hence, there can be no mental illness. 2. ‘Mental Illness’ is a metaphor.  Minds can be ‘sick’ only in the sense that jokes are ‘sick’ or economies are ‘sick.’  3. Psychiatric diagnoses are stigmatizing labels, phrased to resemble medical diagnoses and applied to persons whose behavior annoys or offends others.  4. Those who suffer from and complain of their own behavior are usually classified as ‘neurotic’; those whose behavior makes others suffer, and about whom others complain, are usually classified as ‘psychotic.’  5. Mental illness is not something a person has, but is something he does or is.  6. If there is no mental illness there can be no hospitalization, treatment, or cure for it.  Of course, people may change their behavior or personality, with or without psychiatric intervention.  Such intervention is nowadays called ‘treatment,’ and the change, if it proceeds in a direction approved by society, ‘recovery’ or ‘cure.’  7. The introduction of psychiatric considerations into the administration of the criminal law – for example, the insanity plea and verdict, diagnoses of mental incompetence to stand trial, and so forth – corrupt the law and victimize the subject on whose behalf they are ostensibly employed.  8. Personal conduct is always rule-following, strategic, and meaningful.  Patterns of interpersonal and social relations may be regarded and analyzed as if they were games, the behavior of the players being governed by explicit or tacit game rules.  9. In most types of voluntary psychotherapy, the therapist tries to elucidate the inexplicit game rules by which the client conducts himself; and to help the client scrutinize the goals and values of the life games he plays.  10. There is no medical, moral, or legal justification for involuntary psychiatric interventions.  They are crimes against humanity.”

Szasz’ persuasive and provocative book, along with his essay, earned him both effusive praise and harsh criticism.  He supplied the argument that mental illness is a myth in response to a question that had puzzled the general public, as well as philosophers, sociologists, and medical professionals, a question that may be of more concern today than it was at the time that Szasz published his book and his essay.  The question “What is mental illness?” has often been dismissed, but rarely has it been answered with the kind of precision and accuracy of which Szasz was capable.  Even if it has not been fully or satisfactorily answered, it is still a question worthy of discussion.

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