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.
References
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.
I’ve read many many takes on Insel’s latest admission and this is one of the best. Clear and consise.
Thanks Jonathan!
I am happy that MIA has decided to post an entry on this.
Something I want to contribute is that we should not shy away from the NIMH approach. As a Christian, I do not believe that the mind is only molecules, but I do think that these molecules support the mind.
However here is the great silver lining of the NIMH approach: it is doomed to fail. If the hypothesis that the mind has a life of its own is true (as I believe), for every study that shows bio marker X correlated with behavior why (which is a real brain disease like Alzheimer’s or Parkinson’s), there will another study that with the same data, and under different assumptions, that concludes the opposite. The NIMH approach allows us to falsify psychiatry, while there is no way to falsify “DSM consensus”. In a way, although I am sure this is going to create debate, the NIMH will take psychiatry to “climate change” or “economics” territory, in which psychiatrists will make predictions based on biological data that will not be satisfied most of the time. That will give us in our side the tools to fight the scam very effectively.
This is also compatible with the British DCP’s statement, it is the recognition that minds are not the same as biology and that need to be taken care of differently.
The reason Allen Frances has gone nuts with the DCP’s statement is that both the NIMH and DCP approaches make sense, what it doesn’t make sense is the pseudo science of “in between”, ie, psychiatry as it is practiced now :D.
Jonathan: In my view, your remarks are right on. Yes, Insel’s critique is of the validity of the DSM is much like Szasz’s. But his solution is very different — he sees aberrant behavior as a series of symptoms of biological (brain) illness. The British Psychological Society (?) I think, is similarly critical of the DSM, but adopts a very different solution — preferring to maintain the focus on the psychological level of functioning, and not to reduce it to brain. They may err, however, on an over-emphasis on environmentalist-leaning interpretations of the origins of norm-violating psychological patterns.
In my view, Szasz’ notion that the concept of “mental illness” is conceptually incoherent is correct. However, Szasz’s position WAS too extreme. He advocated a rather rigorous libertarianism — a view in which individuals with psychological problems were seen as primarily responsible for their actions and able to make their own decisions regardless of their degree of impairment. This actually brings back a Cartesian notion of mind and therefore cannot become ill. However, in saying this, Szasz treats the “mind” as some rational and encased process that exists independent from the brain. That’s the only way that he can say, it seems to me, that the person with psychological difficulties necessarily can behave “rationally” and have full responsibility for his or her actions. This goes too far. We need new ideas for understanding the nature of the psychological–ideas that neither reduce conscious agency to brain activity nor define “mind” as something that stands outside of the context of brain activity and the physical body.
Bravo, Jonathan!
IMO, we need to push for both freedom and personal responsibility, at all times.
But if we lose sight of the *fact* that any person can have a breakdown and suffer from emotional distress… need support, understanding, empathy… If we turn our backs and walk away from these folks, ignoring their very *real* suffering (even if we cannot find in by MRI or C-T Scan, we are doomed… lost.
Duane
And helping does *not* mean incarceration, long-term drugs, ECT, or other forms of conventional “treatment.
It means human caring.
Duane
Szasz did not subscribe to a “Cartesian notion of mind”; he didn’t believe in the existence of the “mind” at all.
He correctly perceived that the “mentally ill” and people with actual brain diseases still have reasons (though not necessarily good ones) for what they do, and that their actions are still governed by choices (though not necessarily good ones). Recognizing the moral responsibility of such persons furthers human autonomy and dignity; failing to recognize their moral responsibility diminishes their human status and converts them into grist for the statist psychiatric mill.
Here is an important thought experiment. So, let’s say that neuro-scientists find evidence that some pattern of psychological activity (assuming it could be pinned down to a single pattern) that can be called “depression” correlates with or can be mapped onto brain pattern xyz. The question becomes: If I detect xyz in you, and you do not exhibit the “depressive” psychological pattern in question, are you still depressed? How could the answer to this question possibly be yes? (Unless you want to be bizarre and say, “the person is depressed but asymptomatic.) This is an important question because it doesn’t matter what psychological profile a person exhibits when he or she has diabetes, cancer or heart disease. The disease is defined by the level of insulin, the aberrant growth of the cells, or the clogging of the arteries, regardless of the person’s psychological profile. This suggests that, conceptually (and even if they have biological roots — which ALL psychological processes have), psychological problems are not brain illnesses. Conceptually, psychological problems must be defined psychologically, and with reference to standards and values that define normative forms of psychological activity. This does not rule out the participation of biological processes in aberrant psychological patterns. Biological processes do not operate independent from psychological and socio-cultural processes.
“his 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. ‘
Capitalism and especially the attitudes that developed in the cold war era regarding anything seen as “anti-capitalism”, which was everything to do with social responsibility and government spending. It’s a winners and losers society, where winners are to be awarded and losers are to be discarded. Thomas Szasz, as a libertarian, would agree. People knowing that probably had some bearing on how they treated his arguments.
Szasz didn’t believe that “losers” (in this context, the “mentally ill”) should be “discarded” nor did he believe that assistance shouldn’t be offered to them. As a libertarian, he believed that treatment should not be forced on them.
“For more than fifty years I have maintained that mental illnesses are counterfeit diseases (‘nondiseases’), that coerced psychiatric relations are like coerced labor relations (‘slavery’) or coerced sexual relations (rape), and spent the better part of my professional life criticizing the concept of mental illness, objecting to the practices of involuntary-institutional psychiatry, and advocating the abolition of ‘psychiatric slavery’ and ‘psychiatric rape.’” – Thomas Szasz, M.D.
Szasz was a true hero.
“Not surprisingly, the more aggressively I reminded psychiatrists that individuals incarcerated in mental hospitals are deprived of liberty, the more zealously they insisted that ‘mental illnesses are like other illnesses’ and that psychiatric institutions are bona fide medical hospitals. The psychiatric establishment’s defense of coercions and excuses thus reinforced my argument about the metaphorical nature of mental illness and importance of the distinction between coerced and consensual psychiatry.” – Thomas Szasz, M.D., The Myth of Mental Illness
Duane