Despite being a psychiatrist himself, Thomas Szasz was a lifelong ferocious critic of the institution of psychiatry. He attacked its foundations and practices and questioned its medical legitimacy. Although most psychiatrists remain unconvinced of his arguments, Szasz has been very influential by virtue of being psychiatry’s arch-adversary. A significant body of discourse on the notion of mental disorder by psychiatrists and non-psychiatrists alike has been centered on understanding and responding to his critique.
Szasz’s basic contention is that mental illness is a myth. By asserting this, Szasz is not denying the existence of the conditions that psychiatrists call mental illness, or the suffering and distress experienced by people with these conditions. Rather, he is denying the classification of these conditions as medical diseases. For Szasz, diseases are demonstrable anatomical or physiological lesions, and he frequently refers to Virchow’s notion of cellular pathology as the basis of disease. It follows from this particular definition that the only sort of disease that can exist is physical.
By definition, a disease of the mind is impossible. Disease requires a physical lesion; the mind is nonphysical. Ergo, the mind cannot be diseased. This is a logical deduction; the conclusion follows from the premises. This is what Szasz means when he says that this claim is “an analytic truth, not subject to empirical falsification.”1 Because mental disorders are not diseases in the literal, physical sense, they can only be diseases in a metaphorical sense. Mental illness, he says, “is a metaphor. Minds can be ‘sick’ only in the sense that jokes are ‘sick’ or economies are ‘sick.’”2 Psychiatric diagnoses only mimic medical diagnoses.
If the conditions we call mental illnesses are not diseases, then what are they? Szasz argues that they are in fact problems in living, human conflicts, and unwanted behaviors. “Psychiatrists are not concerned with mental illnesses and their treatments. In actual practice they deal with personal, social, and ethical problems in living.”3 (Szasz’s critique of psychiatry extends to a moral and political dimension as well. He argues that the concept of mental illness undermines the principle of personal responsibility, which is the ground on which all free political institutions rest.)
In this lifelong critique of mental illness as a myth, Szasz simultaneously maintained an interesting counterfactual conditional. In logic, a counterfactual conditional is an if-then statement indicating what would be the case if something were true, although it is not true. While insisting that mental illnesses are in reality problems of living and not diseases, he also argued that if the conditions we call mental disorders are found to have an underlying neuropathology, then it would prove that mental disorders are actually brain disorders, and the whole notion of mental illness was erroneous and superfluous to begin with. Szasz did not believe that mental disorders are brain disorders. He alleged until the end of his life that an underlying pathology for psychiatric disorders had not yet been demonstrated, but he was willing to entertain it as a hypothetical possibility. In his 1960 article “The Myth of Mental Illness,” Szasz wrote4:
The assumption is made that some neurological defect, perhaps a very subtle one, will ultimately be found for all the disorders of thinking and behavior. Many contemporary psychiatrists, physicians, and other scientists hold this view. . . .
I have tried to show that for those who regard mental symptoms as signs of brain disease, the concept of mental illness is unnecessary and misleading. For what they mean is that people so labeled suffer from diseases of the brain; and, if that is what they mean, it would seem better for the sake of clarity to say that and not something else.
In 2011, he reiterated this argument5:
When a person hears me say that there is no such thing as mental illness, he is likely to reply: “But I know so-and-so who was diagnosed as mentally ill and turned out to have a brain tumour. In due time, with refinements in medical technology, psychiatrists will be able to show that all mental illnesses are bodily diseases.” This contingency does not falsify my contention that mental illness is a metaphor. It verifies it. The physician who concludes that a person diagnosed with a mental illness suffers from a brain disease discovers that the person was misdiagnosed: he did not have a mental illness, he had an undiagnosed bodily illness. The physician’s erroneous diagnosis is not proof that the term “mental illness” refers to a class of brain diseases.
Such a process of biological discovery has, in fact, characterised some of the history of medicine, one form of “madness” after another being identified as the manifestation of one or another somatic disease, such as beriberi or neurosyphilis. The result of such discoveries is that the illness ceases to be a form of psychopathology and is classified and treated as a form of neuropathology. If all the conditions now called mental illnesses proved to be brain diseases, there would be no need for the notion of mental illness and the term would become devoid of meaning.
One can clearly see some assumptions at work here. For Szasz the notions of mental illness and brain disease are mutually exclusive. A condition can be either a mental illness or a brain disease—it cannot be both; it can have either a psychopathology or a neuropathology—it cannot have both. This exclusivity springs from the fact that for Szasz mental illness is nondisease (disease in only a metaphorical sense) and psychopathology is nonpathology (pathology in only a metaphorical sense). It is a matter of logic that a condition cannot be nondisease and disease (or nonpathology and pathology) at the same time.
Dr Aftab is Resident in Psychiatry at the Hamad Medical Corporation in Qatar; he is a graduate of King Edward Medical University in Lahore, Pakistan. He reports no conflicts of interest concerning the subject matter of this article.
1. Szasz TS. Preface: the myth of mental illness: foundations of a theory of personal conduct. Fifty Years After The Myth of Mental Illness. 50th anniversary ed. New York: Harper Perennial; 2010:xii.
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