It is obvious that psychiatric disorders and problems in living are somehow related. The connection between the two can be approached from both sides. From the side of problems in living can something be said about these problems which is psychiatrically relevant? From the side of psychiatric disorders what role do problems in living play in psychiatric disorders? After attempting to answer these questions a third question will be considered. How does Szasz defend his statement that psychiatric disorders are problems in living?

So first of all, is there something we can say about problems in living that is relevant to psychiatric disorders? In general what can be said about problems in living is that they can be soluble or insoluble. In the latter case the insolubility can have originated due to changes in the environment. For instance, the fulfillment of the wish to return to one’s birthplace may prove impossible because a highway has been built there. The longing to return to life the way it was before the death of a spouse is equally unrealizable. The insolubility may also be caused by the fact that, although in principle a solution would be possible, that solution would pose demands that for example exceed one’s inventiveness or creativity. Thus this is an interim situation between solubility and insolubility, namely, the problem is in principle soluble, but in practice the person is unable to solve it. Below these will be called relatively insoluble problems. On the side, note that the word problem here also means constellations of problems which can be highly complicated and interlocked.

Two other interrelated aspects of problems in living are significant here: the content of the problem and the way it manifests itself in a particular individual, i.e. the form of expression. The content can regard all sorts of areas in life: contacts, employment, leisure, housing, etc. Sometimes the content of problems is very important, sometimes less. In accordance a person will dedicate from relatively little, through sometimes fairly much, to just about all of his available time to the problem. A problem is always a difficulty, a burden. Serious problems influence the way in which a person behaves. The person may be preoccupied with the problem. His mood may become sullen. He may be stressed, partially withdraw from his contacts, or ask attention from others for his problem. It can grow worse. The person may become depressed. He may despair. The continuity of his life may be temporarily or permanently broken by the problem. In this last case, we can speak of a person who is “broken” by life.

In general it can be posited that the problems that are relevant to psychiatric disorders are characterized by 1. the difficulty identifying them; 2. the difficulty solving them; 3. the way they are expressed.

1. The problem involved in a psychiatric disorder is not completely or completely not clear to the person who has the problem. It may be, for instance, that a person is painfully aware of feeling unfree and inhibited in his contacts with other people without understanding why. It can also be that the original problem has become unrecognizable to the person. This can be taken a step further, positing that the functional significance of a symptom or syndrome is precisely that it causes the problem to become unrecognizable. Psychiatric phenomena cause “interference” which renders the problem incapable of being understood. The reason for this lack of clarity seems in particular to lie in the unbearableness of it for the person who has it. These insights, which were developed by Freud and many others in the framework of psychoanalytic theory, are well-known, and need no further explanation.
One can conceivably wonder whether serious and complicated problems in living do not always harbor unrecognized, unclear components. Freud said that in everybody problems are concealed to a certain degree. This consideration, however, does not diminish the significance of this criterion for problems that involve psychiatric disorders. It can be posited that here again it is a matter of Schwerpunktsbegriff. Although the line between problems of which the structure is totally clear to the person who has the problem and problems for which that is not (totally) the case can be drawn only arbitrarily, there is a clear difference between clear and unclear content or structure of problems.

2. A second hallmark of problems relevant to psychiatric disorders is that the person himself cannot solve it. This precisely becomes apparent by the appearance of symptoms. The psychiatric disorder can be described as a compromise which expresses on the one hand the insolubility of the problem, and on the other, the relative impossibility of living with the problem. This criterion is not completely independent from the first because the insolubility nearly consistently originates in part due to lack of recognition of the problem. Psychotherapy is an attempt to identify the problem. By doing so it can often be solved. But even when the problem is not soluble and part of the tragedy in life, its character changes when it comes into focus. Problems in living which are recognized and experienced as such and are insoluble due to originating from circumstances over which the person has no control, no matter how oppressive and tragic they may be, do not belong to psychiatry, unless the way they are expressed constitutes secondary problems relevant to psychiatry.

In other words, the psychiatric syndrome is the best possible solution to the problem which due to its unbearableness is recognized only partially, while the incomplete recognition contributes to the insolubility. So the psychiatric disorder is the result of both the problem and the person’s response to the problem. An obvious analogy would be a physical illness consisting of both a process which is disrupting homeostasis and the body’s response to that.

3. In the third place, problems relevant to psychiatry are distinguished from other problems in living by their expression. By definition, psychiatric disorders are expressed through experiences and behaviors which satisfy the criteria formulated in 2.1, namely suffering, dysfunction, and abnormality. It is this form in which the problem appears that is typical of psychiatric disorders. Rümke emphasized this aspect of the form of psychiatric disorders. As with bodily disease, the manifestation of the illness in the form of the syndrome significantly determines the disease concept.

When the role of problems in living is viewed from the perspective of the psychiatric disorder it is immediately obvious that the concept of psychiatric disorder is more complicated than the above description of the connections between problems and the expression thereof implies. As yet no or only partial explanations have been provided as to why a certain problem is so unclear to the person who has it, why it is so insoluble, and why it becomes a symptom or syndrome.

In psychiatry a symptom or syndrome is determined by multiple conditions. That means that not one cause (for instance, the problem) is considered to adequately explain it but that such explanation is sought in a network of causes and conditions that are related to heredity, the body, the circumstances in which the person grew up, the way in which he experiences and conducts himself, his network of [social] relationships, the way in which he communicates, other social factors, and finally, cultural factors. In this network of conditions problems in living can significantly contribute to the origin of a syndrome in different ways: as the most important condition or as an auxiliary condition.

In other words, certain problems in living in certain situations within a certain constellation of circumstances requiring further description can cause or have a relevant connection to psychiatric syndromes. Two comments must be made. The first is that the image projected here is too static. It insufficiently emphasizes that we are dealing with processes and not stationary facts. Szasz was right to point out the dangers of such in his introduction to The Myth of Mental Illness. The second comment is that this way of describing other people’s problems is too abstract to elucidate what is essential to them.

These comments are important because precisely in psychiatry there is a risk of considering certain experiences or behaviors phenomena of illness, calling them symptoms, and thereby robbing them of the sense that they may have for the person. The attempt to understand such sense is one of psychiatry’s tasks. Certain phenomena can be both sensible and sick. In other words, a certain phenomenon which is interpreted as illness can at the same time be loaded with significance for the person. The same holds true mutatis mutandis for physical symptoms. Leukocytosis can be considered a symptom of the existence of an infection, and at the same time it is the body’s meaningful response to that infection. “Mutatis mutandis” means here that there is an essential difference of category between the meaning of “meaningful” regarding physical and regarding psychiatric disorders.

How, in view of the above, can Szasz conclude that that which is called mental illness is in reality only problems in living?

Above it was already noted that in psychoanalytic theory, both the unclarity as well as the related insolubility of problems are not directly viewed as part of the ill-healthy polarity. Such problems can be considered neurotic. They occur to a greater or lesser degree in everybody. Whether or not treatment is necessary depends more on the wishes and motivation of the person concerned than on whether there is illness. In this sense the line between healthy and ill is extremely blurry in psychoanalytic theory. A neurotic problem can actually only be counted as belonging to illness when the concept of health is understood as: ideal (2.1). From that point of view it is understandable that Szasz, as a psychoanalyst, does not see a reason to distinguish between illness and health.

Let us look more closely at the experiences and behaviors which can be considered to constitute psychiatric symptoms. Szasz, notably, rarely mentions this formal aspect of psychiatric disorders. Perhaps this is due to his psychoanalytical inclination. In psychoanalytic theory intrapsychic conflict is highlighted rather than its formal forms of expression as symptoms or syndromes. This does not seem to be the only factor. In his criticism of multinational, transcultural research performed by the WHO, Szasz minimizes the significance of symptoms. Repeatedly he contends that so-called symptoms are in fact an interpretation by the person in power who utilizes this interpretation to justify his power over the powerless patient (Schizophrenia, from page 87). The point is that Szasz seems to be so certain that mental illness is but rhetoric intended to conceal conflicts, that considering symptomology would only interfere with his much more important purpose. That purpose is to show that mental illness is not an attribute that belongs to a person but an attribute that is imposed on him by his adversaries.

The third chapter of Schizophrenia is entitled: “Schizophrenia: Psychiatric Syndrome or Scientific Scandal?” Szasz kicks it off with a remark about the meaning of the word syndrome – just about the only one which I was able to find in Szasz’s work – “…And what is a syndrome? According to Webster, it is ‘a group of signs and symptoms that occur together and characterize a disease.’ In short, it is yet another psychosemantic trick to affirm that a ‘disease’ without a demonstrable histopathological lesion or pathophysiological abnormality is nevertheless a disease.” So it is from the vantage of the biomedical disease concept that he criticizes calling schizophrenia a disease. Szasz justifies the existence of symptoms and syndromes only when there is a proven physicochemical disorder which grants disease status to the entire pattern of problems.

My impression is that Szasz mentions the symptoms of mental illness more often in his earlier writings. Interestingly, in his article “The Myth of Mental Illness” he writes about the position that all psychiatric disorders originate from aberrations of the nervous system, “This position implies that people cannot have troubles – expressed in what are now called “mental illnesses” – because of differences in personal needs, opinions, social aspirations, values, and so on.” In the republication of this article in Ideology and Insanity, the modifying phrase in the middle is omitted. Instead, the following sentence is added, “These difficulties – which I think we may simply call problems in living – are thus attributed to physicochemical processes…” (p. 13, my italics). The line of reasoning is entirely dependent on his premise, the biomedical disease concept.

Finally, it is likely that Szasz accords as little attention as possible to the signs and symptoms of psychiatric disorders because in his opinion such would deflect attention from what in his view is the main issue: the stigmatization and dehumanization of powerless people by psychiatrists who hold all the trump cards. This viewpoint of his is regrettable as precisely the abnormal experiences and behaviors that are interpreted as symptoms and syndromes form the strongest argument for speaking of illness to those who maintain a non-biomedical disease concept.

In conclusion, the position that all psychiatric disorders are only problems in living is an untenable simplification.