When Thomas Szasz’s name comes up in debates over defining mental illness, it is fairly common to hear people say something along the lines of, “Well, he made some good points, but he was just too extreme.” Yet I am struck by how conversations about DSM-5, being released this month, make the crisp arguments Szasz consistently offered for 50 years just as timely as ever. I’d even go so far as to suggest that a large number of counselors, psychologists, social workers, and psychiatrists pretty much agree with the main tenets of Szasz’s argument, despite their ongoing disclaimers.
As a refresher for those not up on their Szasz, his basic argument is that “mental illness” is a nonsensical term (Szasz, 1974). Minds differ from brains. Unlike brains, minds aren’t physical and therefore cannot become biologically sick. To think otherwise is to reify a metaphor. The things that DSM-5 says are mental disorders are not diseases the same way heart disease, cancer, and diabetes are because none of them can be explained in terms of specific physiological malfunctions. Yes, some disorders in DSM-5 are likely putative diseases; that is, we suspect that they have physiological bases, even if we haven’t actually discovered them yet.
However, most of the disorders in DSM-5 probably aren’t even putative diseases. They are simply vexing life problems that warrant attention and remediation—things such as coping with divorce, experiencing social isolation, struggling with family conflict, dealing with the stress of economic pressures, and plain old general unhappiness in the face of challenging circumstances. These problems deserve attention to be sure, but those experiencing them aren’t ill in any literal sense. They are simply struggling with the trials and tribulations of everyday life. Life, after all, is often quite hard.
Despite its straightforwardness, Szasz’s contention that mental disorders are not genuine illnesses initially strikes many people as wrongheaded. This is not surprising given how often we have been told that mental illnesses are serious medical conditions afflicting a significant portion of the population—1 in 4 of us, according to the National Institute for Mental Health (NIMH, 2013). Dismissing mental disorders as hokum is often viewed as an affront to all those suffering from them because seeing people as sick allows us to stop blaming them for their problems and start treating them more humanely. This begs the question of why we wouldn’t empathize with or provide assistance to people upset over difficult life circumstances, even if we didn’t think they were ill. However, that’s a question for another day.
Recent events suggest that Szasz’s arguments remain timely. On April 29, the National Institute for Mental Health broke with the DSM, asserting that it will be “re-orienting its research away from DSM categories.” At first glance, the rationale offered sounds like something straight out of Szasz:
The weakness [of DSM] is its lack of validity Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.
In other words, the NIMH acknowledges that mental disorders, as currently defined in DSM, are little more than descriptive conveniences. None of them are diagnosed based on biology. Szasz would have agreed. However, from a Szaszian perspective this leaves things wide open. It means that DSM categories are either (a) putative illnesses whose status as brain diseases (not metaphorical “mental disorders”) might one day be revealed, or (b) problems in living that are currently being misrepresented in medical terms.
The NIMH’s perspective is a bit narrower than Szasz’s. To them, all mental disorders fall into the putative brain diseases category. While they agree with Szasz that mental disorders cannot at present be diagnosed biologically, they remain fully committed to the idea that “mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior.” In their view, it is the DSM that is holding science back from proving that mental disorders are brain diseases. If we just chuck the DSM and redouble our efforts, the elusive biomarkers we seek will be found.
The irony is that both the DSM and the NIMH unintentionally reinforce Szasz’s basic argument when they acknowledge that mental disorders cannot be diagnosed biologically. Where they miss the boat is that they continue to hold out hope that all the problems we currently classify as mental disorders will ultimately be revealed as brain diseases. Some of them perhaps might, but it is likely others never will be. As Szasz knew, many of the problems that psychiatrists, psychologists, counselors, and social workers find themselves dealing with are not physical illnesses. They are problems in living.
Medicine, for all its virtues, will never be able to “treat” (in a literal, medical sense of the term) people who are struggling over whether to quit their jobs, end a relationship, or give up grieving a loved one because to treat such things would mean there would have to be a biological malfunction, rather than a set of life circumstances, triggering these difficulties. Being upset about something does not always—or even usually—mean that one is sick. The negative feelings that life problems evoke are not always diseases. They are usually part and parcel of being human. Most psychotherapists tend to agree with this viewpoint and see the vast majority of their clients as struggling with the emotional consequences of challenging life situations. Only once the DSM and the NIMH acknowledge Szasz’s argument in full is there likely be any progress in differentiating putative brain diseases from problems in everyday living.
Insel, T. (2013, April 29). Transforming diagnosis.
National Institute of Mental Health. (2013). The numbers count: Mental disorders in America.
Szasz, T. S. (1974). The myth of mental illness: Foundations of a theory of personal conduct (rev. ed.). New York, NY: Harper & Row.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.