Classics in theHistory of Psychology
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Christopher D. Green
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The Myth of Mental Illness
By Thomas S. Szasz (1960)
First published inAmerican Psychologist,15, 113-118.
Posted January 2002
My aim in this essay is to raise thequestion"Isthere such athing as mental illness?" and to argue that there is not. Since the notionof mental illness is extremely widely used nowadays, inquiry into the ways inwhich this term is employed would seem to be especially indicated. Mental illness, of course, is not literally a"thing" -- or physical object -- and hence it can "exist"only in the same sort of way in which other theoretical concepts exist. Yet,familiar theories are in the habit of posing, sooner or later -- at least tothose who come to believe in them -- as "objective truths" (or"facts"). During certainhistorical periods, explanatory conceptions such as deities, witches, andmicroorganisms appeared not only as theories but as self-evidentcausesofa vast number of events. I submit thattoday mental illness is widely regarded in a somewhat similar fashion, that is,as the cause of innumerable diverse happenings. As an antidote to the complacent use of the notion of mental illness --whether as a self-evident phenomenon, theory, or cause--let us ask thisquestion: What is meant when it is asserted that someone is mentally ill?
In what follows I shall describe brieflythe main uses to which the concept of mental illness has been put. I shall argue that this notion has outlivedwhatever usefulness it might have had and that it now functions merely as aconvenient myth.
MENTAL ILLNESS AS A SIGN OF BRAINDISEASE
The notion ofmental illness derives it main sup- port from such phenomena as syphilis of thebrain or delirious conditions-intoxications, for instance -- in which personsare known to manifest various peculiarities or disorders of thinking andbehavior. Correctly speaking, however, these are diseases of the brain, not ofthe mind. According to one school ofthought,all so-called mental illness is of this type. The assumption is made that some neurologicaldefect, perhaps a very subtle one, will ultimately be found for all thedisorders of thinking and behavior. Manycontemporary psychiatrists,physicians, and other scientists hold this view. This position implies that peoplecannothavetroubles -- expressed in what arenow called"mentalillnesses" -- because of differences in personal needs, opinions, socialaspirations, values, and so on. Allproblems in livingare attributed to physicochemical processes which in duetime will be discovered by medicalresearch.
"Mental illnesses" are thusregarded as basically no different than all other diseases (that is, of thebody). The only difference, in thisview, between mental and bodily diseases is that the former, affecting thebrain, manifest themselves by means of mental symptoms; whereas the latter,affecting other organ systems (for example, the skin, liver, etc.), manifestthemselves by means of symptoms referable to those parts of the body. This view rests on and expresses what are, inmy opinion, two fundamental errors.
In the firstplace, what central nervous system symptoms would correspond to a skin eruptionor a fracture? It wouldnotbesome emotion or complex bit of behavior. Rather, it would be blindness or aparalysis of some part of the body. The crux of the matter is that a disease ofthe brain, analogous to a disease of the skin or bone, is a neurologicaldefect, and not a problem in living. For example, adefectin a person'svisual field may be satisfactorily explained by correlating it with certaindefinite lesions in thenervoussystem. On the other hand, a person'sbelief -- whetherthis be a belief in Christianity, in Communism, orin theideathat his internal organs are "rotting" and thathis body is, in fact, already "dead" -- cannot be explained by adefect or disease of the nervous system. Explanations of this sort of occurrence -- assuming that one isinterested in the belief itself and does not regard it simply as a"symptom" or expression of something else that ismore interesting-- must be sought along different lines.
The second error in regarding complexpsycho-social behavior, consisting of communications about ourselves and theworld about us, as mere symptoms [p. 114] of neurological functioning isepistemological. In other words, it is an error pertainingnot to any mistakes in observation or reasoning, as such, but rather to the wayin which we organize and express our knowledge. In the present case, the errorlies in making a symmetrical dualism between mental and physical (or bodily)symptoms, a dualism which is merely a habit of speech and to which no knownobservations can be found to correspond. Let us see if this is so. In medicalpractice, when we speak of physical disturbances, we mean either signs (forexample, a fever) or symptoms (for example, pain). We speak of mental symptoms,on the other hand, when we refer to a patient'scommunications abouthimself, others, and the world about him. He might state that he is Napoleon or that he is being persecuted bythe Communists. These would be considered mental symptomsonlyif theobserver believed that the patient wasnotNapoleon or that he wasnotbeing persecuted[sic] by theCommunists. This makes it apparent that the statement that"Xis a mentalsymptom" involves rendering a judgment. The judgment entails,moreover, a covert comparison ormatching of the patient's ideas, concepts, or beliefs with those of theobserver and the society in which they live. The notion of mental symptom is therefore inextricably tied to thesocial(includingethical)contextin which it is made in much the same way as the notion of bodilysymptom is tied to ananatomicalandgenetic context(Szasz,1957a, 1957b).
To sum up whathas been said thus far: I have tried to show that for those who regard mentalsymptoms as signs of brain disease, the concept of mental illness isunnecessary and misleading. For whatthey mean is that people so labeled suffer from diseases of the brain; and, ifthat is what they mean, it would seem better for the sake of clarity to saythat and not something else.
MENTAL ILLNESS AS A NAME FORPROBLEMS IN LIVING
The term "mental illness" iswidely used to describe something which is very different than a disease of thebrain. Many people today take it· forgranted that living is an arduous process. Its hardship for modern man, moreover, derives not so much from astruggle for biological survival as from the stresses and strains inherent inthe social intercourse of complex human personalities. In this context, the notion of mental illnessis used to identify or describe some feature of an individual's so-calledpersonality. Mental illness -- as a deformityof the personality, so to speak -- is then regarded as thecauseof thehuman disharmony. It is implicit in this view that social intercourse betweenpeople is regarded as somethinginherently harmonious,its disturbancebeing due solely to the presence of "mental illness" in many people.This is obviously fallacious reasoning, for it makes the abstraction"mental illness" into acause,even though this abstractionwas created in the first place to serve only as a shorthand expression forcertain types of human behavior. It now becomes necessary to ask: "Whathinds of behavior are regarded as indicative of mental illness, and bywhom?"
The concept of illness, whether bodily ormental,impliesdeviation from someclearlydefined norm.In the case of physical illness, thenorm is the structural and functional integrity of the human body. Thus,although the desirability of physical health, as such, is an ethical value,what healthiscan be stated in anatomical and physiological terms.Whatis the norm deviation from whichis regarded as mental illness? Thisquestion cannot be easily answered. Butwhatever this norm might be, we can be certain of only one thing: namely, thatit is a norm that must be stated in terms ofpsycho-social, ethical,andlegal concepts. For example, notions such as "excessiverepression" or "acting out an unconscious impulse" illustratethe use of psychological concepts for judging (so-called) mental health andillness. The idea that chronichostility, vengefulness, or divorce are indicative of mental illness would beillustrations of the use of ethical norms (that is, the desirability of love,kindness, and a stable marriage relationship). Finally, the widespread psychiatric opinion that only a mentally illperson would commit homicide illustrates the use of a legal concept as a normof mental health. The norm from which deviation is measured whenever one speaksof a mental illness is apsycho-social and ethical one. Yet, the remedy is sought in terms ofmedicalmeasures which -- it is hoped andassumed -- are free from wide differences of ethical value. The definition of the disorder and the termsin which its remedy are sought are therefore at serious odds with oneanother. The practical significance ofthis covert conflict between the alleged nature of the defect and the remedycan hardly be exaggerated.
Having identified the norms used tomeasure [p. 115] deviations in cases of mental illness, we will now turn to thequestion: "Who defines the norms and hence the deviation?" Two basicanswers may be offered:(a)It may be the person himself (that is, thepatient) who decides that he deviates from a norm. For example, an artist may believe that hesuffers from a work inhibition; and he may implement this conclusion by seekinghelpforhimself from a psychotherapist. (b)It may be someone other than the patient who decides that the latter is deviant(for example, relatives, physicians, legal authorities, society generally,etc.). In such a case a psychiatrist maybe hired by others to do somethingtothe patient in order to correctthe deviation.
Theseconsiderations underscore the importance of asking the question "Whoseagent is the psychiatrist?" and of giving a candid answer to it (Szasz,1956, 1958). The psychiatrist(psychologist or nonmedical psychotherapist), it now develops, may be the agentof the patient, of the relatives, of the school, of the military services, of abusiness organization, of a court of law, and so forth. In speaking of thepsychiatrist as the agent of these persons or organizations, it is not impliedthat his values concerning norms, or his ideas and aims concerning the propernature of remedial action, need to coincide exactly with those of hisemployer. For example, a patient inindividual psychotherapy may believe that his salvation lies in a new marriage;his psychotherapist need not share this hypothesis. As the patient's agent,however, he must abstain from bringing social or legal force to bear on thepatient which would prevent him from putting his beliefs into action. If hiscontractis with the patient, the psychiatrist (psychotherapist) may disagree withhim or stop his treatment; but he cannot engage others to obstruct thepatient's aspirations. Similarly, if a psychiatrist is engaged by a court todetermine the sanity of a criminal, he need not fully share the legalauthorities' values and intentions in regard to the criminal and the meansavailable for dealing with him. But the psychiatrist is expressly barred fromstating, for example, that it is not the criminal who is "insane" butthe men who wrote the law on the basis of which the very actions that are beingjudged are regarded as "criminal." Such an opinion could be voiced, of course, but not in a courtroom, andnot by a psychiatrist who makes it his practice to assist the court inperforming its daily work.
To recapitulate: In actual contemporarysocial usage, the finding of a mental illness is made by establishing adeviance in behavior from certain psychosocial, ethical, or legal norms. The judgment may be made, as in medicine, bythe patient, the physician (psychiatrist), or others. Remedial action, finally, tends to be soughtin a therapeutic -- or covertly medical -- framework, thus creating a situationin whichpsychosocial, ethical,and/orlegaldeviationsareclaimed to be correctible by (so-called)medical action. Since medical action is designed tocorrect only medical deviations, it seems logically absurd to expect that itwill help solve problems whose very existence had been defined and establishedon nonmedical grounds. I think that theseconsiderations may be fruitfully applied to the present use of tranquilizersand, more generally, to what might be expected of drugs of whatever type inregard to the amelioration or solution of problems in human living.
THE ROLE OF ETHICS IN PSYCHIATRY
Anything thatpeopledo -- incontrastto things thathappento them (Peters, 1958) -- takes place in a contextof value. In this broad sense, no humanactivity is devoid of ethical implications. When the values underlying certainactivities are widely shared, those who participate in their pursuit may losesight of them altogether. The disciplineof medicine, both as a pure science (for example, research) and as a technology(for example, therapy), contains many ethical considerations andjudgments. Unfortunately, these areoften denied, minimized, or merely kept out of focus; for the ideal of themedical profession as well as of the people whom it serves seems to be having asystem of medicine (allegedly) free of ethical value. This sentimental notionis expressed by such things as the doctor's willingness to treat and helppatients irrespective of their religious or political beliefs, whether they arerich or poor, etc. While there may besome grounds for this belief -- albeit it is a view that is not impressivelytrue even in these regards -- the fact remains that ethical considerationsencompass a vast range of human affairs. By making the practice of medicineneutral in regard to some specific issues of value need not, and cannot, meanthat it can be kept free from all such values. The practice of medicine isintimately tied to ethics; and the first thing that we must do, it seems to me,is to try to make this clear and explicit. I shall [p. 116] let this matter rest here, for it does not concern usspecifically in this essay, Lest therebe any vagueness, however, about how or where ethics and medicine meet, let meremind the reader of such issues as birth control, abortion, suicide, andeuthanasia as only a few of the major areas of current ethicomedicalcontroversy.
Psychiatry, I submit, is very much moreintimately tied to problems of ethics than is medicine. I use the word"psychiatry" here to refer to that contemporary discipline which isconcerned withproblems in living(and not with diseases of the brain,which are problems for neurology). Problems in human relations can be analyzed, interpreted, and givenmeaning only within given social and ethical contexts. Accordingly, itdoesmakea difference -- arguments to the contrary notwithstanding -- what thepsychiatrist's socioethical orientations happen to be; for these will influencehis ideas on what is wrong with the patient, what deserves comment orinterpretation, in what possible directions change might be desirable, and soforth. Even in medicine proper, thesefactors play a role, as for instance, in the divergent orientations whichphysicians, depending on their religious affiliations, have toward such thingsas birth control and therapeutic abortion. Can anyone really believe that a psychotherapist's ideas concerningreligious belief, slavery, or other similar issues play no role in hispractical work? If they do make a difference, what are we to infer fromit? Does it not seem reasonable that weought to have different psychiatric therapies -- each, expressly recognized forthe ethical positions which they embody -- for, say, Catholics and Jews,religious persons and agnostics, democrats and communists, white supremacistsand Negroes, and so on? Indeed, if welook at how psychiatry is actually practiced today (especially in the UnitedStates), we find that people do seek psychiatric help in accordance with theirsocial status and ethical beliefs (Hollingshead & Redlich, 1958). This should really not surprise us more thanbeing told that practicing Catholics rarely frequent birth control clinics.
The foregoingposition which holds that con- temporary psychotherapists deal with problems inliving, rather than with mental illnesses and their cures, stands in oppositionto a currently prevalent claim, according to which mental illness is just as"real" and "objective" as bodily illness. This is aconfusing claim since it is never known exactly what is meant by such words as"real" and "objective." I suspect, however, that what isintended by the proponents of this view is to create the idea in the popularmind that mental illness is some sort of disease entity, like an infection or amalignancy. If this were true, one couldcatchor get a "mentalillness," one mighthaveorharborit, one mighttransmitit to others, and finally one could getridof it. In my opinion, there is not a shred ofevidence to support this idea. To thecontrary, all the evidence is the other way and supports the view that whatpeople now call mental illnesses are for the most partcommunications expressing unacceptable ideas, often framed,moreover, in an unusual idiom. The scopeof this essay allows me to do no more than mention this alternative theoreticalapproach to this problem (Szasz, 1957c).
This is not theplace to consider in detail the similarities and differences between bodily andmental illnesses. It shall suffice forus here to emphasize only one important difference between them: namely, thatwhereas bodily disease refers to public, physicochemical occurrences, thenotion of mental illness is used to codify relatively more private,sociopsychological happenings of which the observer (diagnostician) forms apart. In other words, the psychiatristdoes not standapartfrom what he observes, but is, in Harry StackSullivan's apt words, a "participant observer." This means that he iscommittedtosome picture of what he considers reality -- and to what he thinks societyconsiders reality -- and he observes and judges the patient's behavior in thelight of these considerations. Thistouches on our earlier observation that the notion of mental symptom itselfimplies a comparison between observer and observed, psychiatrist and patient. This is so obvious that I may be charged withbelaboring trivialities. Let metherefore say once more that my aim in presenting this argument was expresslyto criticize and counter a prevailing contemporary tendency to deny the moralaspects of psychiatry (and psychotherapy) and to substitute for them allegedlyvalue-free medical considerations. Psychotherapy, for example, is being widely practiced asthoughit entailed nothing other thanrestoring the patient from a state of mental sickness to one of mental health.While it is generally accepted that mental illness has something to do withman's social (or interpersonal) relations, it is paradoxically maintained thatproblems of values (that is, of ethics) do not [p. 117] arise in this process.[1] Yet, in one sense,much of psychotherapy may revolve around nothing other than the elucidation andweighing of goals and values -- many of which may be mutually contradictory --and the means whereby they might best be harmonized, realized, or relinquished.
The diversityof human values and the methods by means of which they may be realized is sovast, and many of them remain so unacknowledged, that they cannot fail but leadto conflicts in human relations. Indeed,to say that human relations at all levels -- from mother to child, throughhusband and wife, to nation and nation -- are fraught with stress, strain, anddisharmony is, once again, making the obvious explicit. Yet, what may be obvious may be also poorlyunderstood. This I think is the case here. For it seems to me that -- at least in our scientific theories ofbehavior -- we have failedtoacceptthesimplefact that humanrelations are inherently fraught with difficulties and that to make them evenrelatively harmonious requires much patience and hard work. I submit that theidea of mental illness is now being put to work to obscure certain difficultieswhich at present may be inherent -- not that they need be unmodifiable -- inthe social intercourse of persons. Ifthis is true, the concept functions as a disguise; for instead of callingattention to conflicting human needs, aspirations, and values, the notion ofmental illness provides an amoralandimpersonal"thing" (an "illness")as an explanation forproblems in living(Szasz, 1959). We may recall in this connection that not solong ago it was devils and witches who were held responsible for men's problemsin social living. The belief in mentalillness, as something other than man's trouble in getting along with his fellowman, is the proper heir to the belief in demonology and witchcraft. Mentalillness exists or is "real" in exactly the same sense in whichwitches existed or were "real."
CHOICE, RESPONSIBILITY, ANDPSYCHIATRY
While I haveargued that mental illnesses do not exist, I obviously did not imply that thesocial and psychological occurrences to which this label is currently beingattached also do not exist. Like thepersonal and social troubles which people had in the Middle Ages, they are realenough. It is the labels we give themthat concerns us and, having labelled them, what we do about them. While I cannot go into the ramifiedimplications of this problem here, it is worth noting that a demonologicconception of problems in living gave rise to therapy along theological lines.Today, a belief in mental illness implies -- nay, requires--therapy alongmedical or psychotherapeutic lines.
What isimplied in the line of thought set forth here is something quitedifferent. I do not intend to offer anew conception of "psychiatric illness" nor a new form of "therapy." My aim is more modest and yet also moreambitious. It is to suggest that the phenomena now called mental illnesses belooked at afresh and more simple, that they be removed from the category ofillness, and that they be regarded as the expressions of man's struggle withthe problem ofhowhe should live. The last mentioned problem isobviously a vast one, its enormity reflecting not only man's inability to copewith his environment, but even more his increasing self-reflectiveness.
By problems in living, then, I refer tothat truly explosive chain reaction which began with man's fall from divinegrace by partaking of the fruit of the tree of knowledge. Man's awareness of himself and of the worldabout him seems to be a steadily expanding one, bringing in its wake an everlarge;burden of understanding(an expression borrowed from SusanneLanger, 1953).This burden,then,is to be expected and must not bemisinterpreted.Our onlyrationalmeans for lightening it ismoreunderstanding,and appropriateactionbased on such understanding.The main alternative lies in acting as though the burden were not what in factwe perceive it to be and taking refuge in an outmoded theological view of man.In the latter view, man does not fashion his life and much of his world abouthim, but merely lives out his fate in a world created by superior beings. Thismay logically lead to pleading nonresponsibility in the face of seeminglyunfathomable problems and difficulties. Yet, if man fails to take increasing responsibility for his [p. 118]actions, individually as well as collectively, it seems unlikely that somehigher power or being would assume this task and carry this burden for him.Moreover, this seems hardly the proper time in human history for obscuring theissue of man's responsibility for his actions by hiding it behind the skirt ofan all-explaining conception of mental illness.
CONCLUSIONS
I have tried to show that the notion ofmental illness has outlived whatever usefulness it might have had and that itnow functions merely as a· convenient myth. As such, it is a true heir to religious myths in general, and to thebelief in witchcraft in particular; the role of all these belief-systems was toact associal tranquilizers,thus encouraging the hope that mastery ofcertain specific problems may be achieved by means of substitutive(symbolic-magical) operations. The notion of mental illness thus servesmainly to obscure the everyday fact that life for most people is a continuousstruggle, not for biological survival, but for a "place in the sun,""peace of mind," or some other human value. For man aware of himselfand of the world about him, once the needs for preserving the body (and perhapsthe race) are more or less satisfied, the problem arises as to what he shoulddo with himself. Sustained adherence to the myth of mental illness allowspeople to avoid facing this problem, believing that mental health, conceived asthe absence of mental illness, automatically insures the making of right andsafe choices in one's conduct of life. But the facts are all the other way. Itis the making of good choices in life that others regard, retrospectively, asgood mental health!
The myth ofmental illness encourages us, moreover, to believe in its logical corollary:that social intercourse would be harmonious, satisfying, and the secure basisof a "good life" were it not for the disrupting influences of mentalillness or "psychopathology." The potentiality for universal human happiness, in this form at least,seems to me but another example of the I-wish-it-were-true type of fantasy. Ido [*] believe that human happiness or well-being on ahithertounimaginablylargescale, and not just for a select few, is possible. This goal could be achieved, however, only atthe cost of many men, and not just a few being willing and able to tackle theirpersonal, social, and ethical conflicts. This means having the courage and integrity to forego waging battles onfalse fronts, finding solutions for substitute problems -- for instance,fighting the battle of stomach acid and chronic fatigue instead of facing up toa marital conflict.
Ouradversaries are not demons, witches, fate, or mental illness. We have no enemy whom we can fight, exorcise,or dispel by"cure." What we do have areproblems inliving-- whetherthese bebiologic, economic, political, or sociopsychological. In this essay I was concerned only withproblems belonging in the last mentioned category, and within this group mainlywith those pertaining to moral values. The field to which modern psychiatry addresses itself is vast, and Imade no effort to encompass it all. My argument was limited to the propositionthat mental illness is a myth, whose function it is to disguise and thus rendermore palatable the bitter pill of moral conflicts in human relations.
References
HOLLINGSHEAD, A. B., & REDLICB, F. C.Social class and mental illness. NewYork: Wiley, 1958.
JONES, E.Thelife and work of Sigmund Freud.Vol. III. New York: Basic Books, 1957.
LANCER, S.R. Philosophyina newhey. New York: Mentor Books, 1953.
PETERS, R. S.Theconcept of motivation.London: Routledge & Kegan Paul, 1958.
SZASZ, T. S.Malingering: "Diagnosis" or social condemnation? AMA Arch Neurol. Psychiat.,1956,76, 432-443.
SZASZ, T. S.Painand pleasure: A study of bodily-feelings.New York: Basic Books, 1957. (a)
SZASZ, T.S. The problem of psychiatric nosology:A contribution to a situational analysis of psychiatric operations. Amer. J. Psychiat,1957,114, 405-413. (b)
SZASZ, T.S. On the theory of psychoanalytictreatment.Int. J.Psycho-Anal.,1957,38, 166-182. (c)
SZASZ, T.S. Psychiatry, ethics and the criminal law.Columbia law Rev.,1958,58, 183-198.
SZASZ, T.S. Moral conflict and psychiatry, Yale Rev.,1959, in press.
Footnote
[1] Freud went so far asto say that: "I consider ethics to be taken for granted. Actually I have never done a mean thing"(Jones, 1957, p. 247). This surely is astrange thing to say for someone who has studied man as a social being asclosely as did Freud. I mention it hereto show how the notion of "illness" (in the case of psychoanalysis,"psychopathology," or "mental illness") was used by Freud-- and by most of his followers -- as a means for classifying certain forms ofhuman behavior as falling within the scope of medicine, and hence· (byfiat)outside that of ethics!
[*]Classics Editor's note: In the originalAmerican Psychologist text the word"not" appears at this point. Dr. Szasz has informed me, however, thatit "was a typo, which [he] corrected when [he] reprinted the piece, e.g.,inIdeology and Insanity"(personal communication, 2002).