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The Myth of Mental Illness (1961)

This book first appeared in 1961, and a second edition appeared in 1974. The differences between the two editions are mostly editorial changes. In the second edition the phrasing has become noticeably more sharp and resolute. Nearly all mitigating phrases have been omitted, and the author seems to leave his readers less room for their own thoughts about his views. There is, however, no essential difference in content and meaning in the two editions.

The first part of The Myth of Mental Illness consists of an examination of the origins and foundations for current psychiatric theory and practice. The second part offers an alternative view on mental illness and how to speak about it meaningfully. In this second part, not only psychoanalytic points of view are presented, but also social-psychological, linguistic, and system theoretical points of view.

The book revolves around a number of premises. The first is that mental illness does not exist. The idea that there is such a thing as mental illness is a “myth,” arising from a “category-error” as Ryle describes it. According to Szasz, the concept of illness is applicable only to bodily aberrations that can be demonstrated by physical and chemical methods. “Strictly speaking, disease or illness can affect only the body.” (p. 275) As there is no demonstrable aberration of the body in mental illness – when there is such, we should speak of an internal or neurological illness, whichever the case may be – the concept of illness is not applicable, therefore there can be no such thing as mental illness. When in certain aspects mental illness resembles physical illness, this does not mean that mental illness is a real disease. The word illness used in this way is a metaphor.

Until the middle of the nineteenth century and later, according to Szasz, illness was defined as a physical disorder. The disorder had to be physicochemically demonstrable in the form and structure of the body. Many new diseases that conformed to this criterion were discovered and described. Psychiatry could only enter the domain of medicine by changing this criterion for illness. Aside from the demonstrable change in body structure, a changed function of the body, discernible by studying behavior, was added as a criterion. Thus structural and functional aberrations were placed in the same category. I remark here that Szasz thus unified functional and behavioral criteria. The function of organs or organ systems are assigned to the same category as the behavior of an individual, and contrasted to physicochemical changes. This view seems incorrect to me.

Szasz presents hysteria as paradigmatic of this development. Hysterical patients who formerly were considered and treated as malingerers were introduced into the domain of medicine by Charcot, an operation that was completed by Freud. Thus malingerers were promoted to patients. For a commentary on this historical reconstruction see Chapter II, 2.

The hysterical conversion phenomena – somatic symptoms that cannot be ascribed to a physicochemical defect in the body – Szasz continues, confront the investigator with the difference between real and fake. A disorder is suggested and imitated that in reality does not exist. Hysteria is a fake disease. This leads to the conclusion that all mental illness is fake illness.

As mental illness does not exist, the entire body of medical terminology used in psychiatry is senseless. If there is no question of illness, there can also be no question of diagnosis and treatment. Psychiatric interventions are forms of social, thus ultimately moral treatment, not medical interventions. It is therefore wrong to accept any psychiatric intervention whatsoever when the only ground for it is that it is considered a form of medical treatment.

The second premise is that a diagnosis is not only a physician’s subjective judgment of what is going on, as the presence of disease can be proved by demonstrating the corresponding physicochemical disorder. However, in the case of mental illness, diagnoses cannot be verified. That means that a psychiatric diagnosis is nothing other than the unverifiable or incontestable judgment of one person, the psychiatrist, of another person, the patient. There is no objective criterion by which it is possible to prove that the psychiatrist is right. So if the psychiatrist and his patient disagree – for instance if the patient contends that he is not ill – the issue is settled by the difference in power between the two. That means that regarding psychiatric illness we cannot speak of discovering but rather inventing a new class of illnesses. In other words, mental illness does not exist in the natural world, but is a behavior that is declared an illness by the doctor.

As in Western culture medicine, including psychiatry, increasingly gains importance to man, more and more behavioral patterns are labeled mental illness. The importance of whether certain behaviors are ascribed to mental illness is equally growing. This entire development unfolded without any contextual justification, as the corresponding physical aberrations that have to be demonstrated in order to speak of illness were never found. Thus there must have been other, strategic motivations for continued psychiatrization. Szasz considers one of the reasons for this psychiatrists’ gained prestige. By maintaining medical concepts, psychiatrists share the prestige of physicians.

The third premise is that the concept of illness itself has not only a contextual but also a strategic significance. This was already clarified by the transformation of the social role of hysterics from malingerers to patients. Thus relabeling simulation as mental illness means restoring social honor to people who are now cast into the patient role, as well as entitling them to the privileges and welfare payments of the sick. As sick people, patients are no longer responsible for their illness, but victims of it. They deserve sympathy rather than the scorn accorded to malingerers.

Although this improvement in social status with corresponding improvement in living conditions in itself is to be appreciated as advantageous to these people, at the end of the day the maneuver is to be valued negatively. The problem posed to themselves and others by people suffering from hysteria is not changed, in spite of the changed label. So the problem is not solved but rather concealed. That is why in spite of the changed semantics and social reclassification, the mentally ill have the same bad reputation as the malingerers of the nineteenth century. The label of mental illness is a stigma suggesting inferiority, causing people so labeled to be socially excluded. It is even a useful tool for the express purpose of social discrimination. The cure generates a new disease: instead of social rehabilitation, mental illness now means social discrimination.

At this point another important social implication comes to mind. Life is difficult, and people have always sought excuses for personal failure. By labeling all sorts of deviant patterns and behaviors as mental illness, personal failure turns into being victimized by illness. That which is in fact human activity is turned into a process to which people are subjected and over which they are powerless. Concealing the true – in the revised edition, in essence, moral and political – significance of the phenomena and behaviors that are labeled mental illness, serves as a semantic tranquilizer. The problems in personal and social relationships that have been obscured and explained away by the label of mental illness have therefore become insoluble.

Although mental illness does not exist, the behavior that leads to such a label does, of course. In the second half of the book an alternative model explaining hysteria is designed. Szasz fairly exclusively limits himself to hysterical conversion phenomena in this model, although he states that the model is applicable to hysteria as such.

In his model, Szasz utilizes the concepts of role, rule, and game, in addition to psychoanalytic views. He bases them on the game model of human behavior as formulated by George Herbert Mead in 1934. Although the concepts of role, rule, and game are used metaphorically throughout the book, Szasz conspicuously never mentions that he is using metaphors. This is all the more peculiar as he repeatedly emphasizes the metaphoric nature of the concept of mental illness, which is the cornerstone of his argument.

Hysterical conversion, then, can be described as a certain type of communication that mainly utilizes iconic signs. An iconic sign is a symbol that outwardly resembles the object symbolized. For instance, a photograph of a person is an iconic sign of that person. This form of communication may emerge when direct verbal communication becomes difficult or impossible. Furthermore, conversions transmit incorrect information as the physical disorder does not really exist. Such information can also be characterized as indirect, like the manifest content of a dream is an indirect form of communication, in which the true message – the latent content of the dream – is both concealed and revealed.

Through the conversion people signal helplessness and so request help, as helplessness appeals to helpfulness. This connection can be explained as follows. First is the fact that children are helpless and powerless, and cannot survive without the support of adults. Children’s helplessness evokes a strong urge to help in adults. A somewhat similar process occurs when adults present themselves as helpless and powerless, and as such behave more or less like children. Second is the influence of the most important western religions, Christianity in particular, which command a helpful attitude towards the weak, sick, and helpless. Thereby they in fact encourage rewarding an attitude of humiliation, poverty, dependence, and powerlessness.

When human behavior is considered like a game that follows certain rules and aims at a certain objective, it can be stated that through conversion a person plays the game of helplessness, the objective being to dominate others. The typical strategy is that the person with the conversion, by appearing weak and helpless, motivates or compels others to do all sorts of things.

Human behavior follows rules. These rules can be divined by studying the social context of behavior. Examining this further leads Szasz to the conclusion that the behavior of people with hysteria, like the behavior of “normal” people, follows strategic rules. This means that it is meaningful and aimed at reaching a certain objective. But if so, then also from this point of view hysteria is not an illness. Illness, by definition, is a defect or blemish, and not intact, albeit unusual, functioning. Furthermore, viewing hysteria from the perspective of rule, role, and game implies that the methods by which meaningful information about hysteria can be collected have a lot in common with those of linguistics, sociology, and communication sciences. So they are not the methods of physics and chemistry, which can neither clarify human symbolic behavior nor explain it by somatic deviance found when examining the body. He generalizes this reasoning to all mental illness.

In short: mental illness does not exist. It is a socially reprehensible concept because it stigmatizes and discriminates against those labeled with it. It conceals the life problems and conflicts people have with each other, and by calling them illness, makes them insoluble.

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