Intro

“My aim in this essay is to raise the question of whether there really is such a thing as what we call mental illness – and to show that there is not.”

This is how the radical American psychiatrist Thomas Szasz, who was convinced that mental disorders do not exist, begins his essay. If a psychiatrist attacks his own field, he must have a good reason for it and, above all, well-founded arguments. He developed them a year after publishing the essay, in a book of the same name. So what is the author trying to do, and what reasons does he put forward for rejecting the conception of mental disorder of his time? Is there anything in the essay that is relevant to today’s philosophy and psychiatry too?

The ontology of mental disorder

A mental disorder is not a physical thing that we could touch. We will not find a mental disorder anywhere in the human body. The term “mental disorder” is a theoretical concept, whatever position and philosophy we hold. And like all theoretical concepts, it is abstract and exists only in our mind, in our language. Abstraction is one of the functions of natural language that helps us talk about complex things. Scientific disciplines are full of theoretical concepts that have no physical existence. The physical notions of the ether, the black hole, quarks or the Higgs boson were until recently merely theoretical constructs. They existed only as predictions of a physical theory. Their existence was verified empirically only much later. In the case of the ether, however, it turned out that what had been considered a real physical entity does not exist. Today, notions such as dark energy or dark matter still belong among the theoretical concepts that help us better understand the complexity and workings of the universe; they have explanatory power, but we cannot be sure whether they really exist as physical entities of the world, or indeed whether we will ever be able, at least in theory, to observe them in the future.

Theoretical concepts are nothing bad in themselves; science cannot do without them. The problem begins when we start to understand something theoretical as having, by itself, an influence on and an impact on the physical world. We then mistake an invented linguistic label, which is a useful shorthand in our speech, for something with the causal power to affect, say, a person’s health and behaviour. This process, in which abstract and theoretical things are assigned a physical, material existence, is called reification (res = thing, facere = to make, literally = thing-making, in plainer English = turning into a thing)

Although he did not call it that himself, Szasz thinks that “mental disorder” belongs precisely to this category of reified things, in which we begin to attribute objective truth, existence and causal influence over events to abstract ideas. Szasz questions the physical, material existence of what is called “mental disorder”. He claims that the concept has outlived its usefulness and is nothing but an entrenched myth, just as – argues the author as an atheist materialist – medicine and society once attributed causal influence to deities or witches.

In his article Thomas Szasz questions everything we thought about mental disorders then, and still think today. The author is aware that he is going against the current of the thinking of his time, and so he begins his critique by analysing what the psychiatric literature actually means when it speaks of mental disorder. He starts with the fact that some other authors reduce mental disorder to the manifestations of a physical disease of the brain.

Mental disorder as a disease of the brain

The author does not dispute that there are various disorders that affect thinking and behaviour. Syphilis or intoxication, for example, affect our brain, and such damage has an impact on the individual’s mental state. Szasz refers to the experts of his day who considered all mental disorders to be disorders of this type. According to these experts, however, these are, strictly speaking, not mental disorders but disorders of the brain. And all these disorders can be, or soon will be, reduced to physical and chemical processes in the body. If we agree with such a view, it seems that we do not need a separate concept of “mental disorder”. Whatever a mental disorder is, we will find its cause in the physicochemical processes of the brain, and so it makes sense to stop speaking of such a problem as mental, since that only obscures the real nature of the problem and causes conceptual chaos. Instead, we should always speak of a problem of the brain.

Szasz, however, does not agree with such an interpretation. According to him, there is a special category of mental disorders arising from so-called “problems in living” – personal needs, motivations, opinions, aspirations, values, etc. – which cannot be reduced to chemical processes, nor located in some part of the brain. If people believe in nonsense, in things that do not exist, or have abnormal and pathological interests, then according to Szasz we will not find the causes in the brain. [The author is wrong here, but more on that later].

While some authors would reduce mental disorders to physicochemical processes, Szasz, in my view, falls on the opposite side of the imaginary spectrum and reduces all mental disorders to problems that can be solved by psychotherapeutic intervention. But first let us look at what Szasz actually means by these problems in living.

Mental disorder as a label for problems in living

Szasz counts among the main errors of contemporary social thought the fact that we think life is fundamentally harmonious, simple and unproblematic. When we come across some difficulties and complexities that we cannot cope with, it is something abnormal and we need medical, psychiatric intervention. It might seem that Szasz will set off in an existential direction and talk about life being an existential problem and difficulties forming an integral part of our human existence. Yes and no. Szasz indirectly describes two types of approach to mental disorders, which I call ethical and psychotherapeutic.

The ethical approach

The ethical approach comes close to a sociological critique of psychiatry à la Michel Foucault (see e.g. my article Michel Foucault and the Concept of the “Dangerous Individual” in 19th-Century Psychiatry), in which themes such as power, the relativisation of values, the subjectivity of judging who and what is ill, and the role of the psychiatrist as the one who, in the name of state power, watches over abnormal individuals and carries out a kind of hygienic cleansing of society all figure.

Szasz’s approach, which thus appears to me as problematising the ethical dimension of psychiatry, criticises a basic assumption on which society is set up. Namely, that life under normal circumstances is harmonious, and that society understands any departure from it as a deviation from some norm. And this deviation needs to be dealt with, removed and ideally prevented in the future, so that it does not threaten the “normal” majority of the population. But who defines what is normal and which norms should be followed? In most cases it is precisely the psychiatrist, who, through his socialisation in the given society, has to interpret what appears abnormal in the speech of the individual in question.

The psychiatrist, in Szasz’s view, is an expert appointed by society who assesses the abnormality of the given patient’s behaviour, opinions and thoughts. The psychiatrist becomes a critic and interpreter of the life story and verbal expression of the potential patient. The psychiatrist does not do this from scratch. Rather, he inevitably interprets the patient’s behaviour on the basis of his own life experience in a very specific social and cultural context, and on the basis of his worldview of what he considers reality, the norm, the standard.

In the article we find the interesting term participant observer, with which he describes how the psychiatrist is not merely an analytical and objective observer, but himself enters into the process of defining who is ill and how. Similarly, we can imagine a literary critic who, through his character, his knowledge, but also his taste, chooses what to focus on in a given book, poem or novel. The analogy is not exact, because psychiatry has statistically and scientifically grounded tables and methods for assessing a patient’s condition, but we cannot expect a psychiatrist’s personal and subjective judgement not to enter into the seemingly objective process of assessing a mental disorder. After all, several psychiatrists often do not agree on a single diagnosis; that in itself should suggest to us that psychiatry is certainly not an exact science; but neither is medicine.

It is precisely this unwarranted stamp of exactness that Szasz criticises in psychiatry. As the author writes: “no human activity is devoid of human value”[1]. That, however, would mean that medicine itself is also permeated by human values, which bring into medicine an element of personal taste and judgement, that is, of subjectivity. The author is aware of this too, which is why he has to argue that although medicine is also bound up with ethical and subjective judgements, psychiatry is much more so[2].

The ethical approach and the problem of communication

Perhaps the most controversial moment in the essay is found in the passages where Szasz tries to reduce all mental problems that cannot be identified as physicochemical (that is, as problems of the brain) to problems of communication – of how a person speaks, what they express, how they react. When a psychiatrist does not understand someone’s speech or considers it “inappropriate”, he labels it “abnormal”, and psychiatrists codify it medically as a “symptom” of some disease. Szasz writes:

“mental illnesses are in fact communications expressing unacceptable ideas, often framed, moreover, in an unusual idiom.”

Certainly, we find many examples in history where the expression of strange opinions was considered a manifestation of mental disorder. In the Soviet Union, for example, many people ended up not only in prison but also in psychiatric clinics simply because they had the courage to express politically incorrect opinions. Let us recall George Orwell’s 1984, in which the main character, Winston Smith, is sent to Room 101 for torture and re-education because of his opinions. From this cynical point of view, psychiatry can be understood as an instrument of social control – much like thoughtcrime in Orwell’s novel.

But is it possible to reduce all the strange things people say to a psychiatrist judging something we say to be strange and unacceptable? After all, abnormal linguistic expressions are a legitimate symptom of a serious health problem. Various lesions of the temporal or frontal lobe can cause delusions and hallucinations. Szasz is therefore wrong when he claims that these strange opinions and beliefs, that someone is Napoleon or is being persecuted by the CIA, cannot be caused and explained by a defect or disease of the nervous system.[3]

Finding the cause of a delusion is a complex task. All the more so if we want to be precise.

On the one hand, it is a true claim that the psychiatrist has to judge, on the basis of his own interpretation, that something is happening to the patient because the patient is saying nonsensical things. The psychiatrist would then, with the help of magnetic resonance images and a neurologist’s opinion, pronounce the diagnosis that the cause of the delusion is a lesion in the brain. On the other hand, psychiatry can no longer explain to us why that particular lesion in that particular place manifests itself in this particular way. In other words, why does a physical disorder of the brain manifest itself as a delusion of persecution by the CIA and not, say, of persecution by the Chinese Communist Party?

That is a question I have no answer to. And I doubt that Szasz or psychiatry itself has an answer to it. It would seem reasonable to me to analyse the history of such a patient and find out whether and how he was interested in the CIA or in American politics and history. But I can imagine that there are cases where, for example, a radical atheist suddenly saw the Virgin Mary or Jesus, even though in his intellect and opinions he was convinced of the very opposite. What then with such a person? Can we understand his delusions (let us assume that they are delusions and not a true revelation) as being based on his knowledge and interests? And even if that were so, it seems to me that in the next 20–30 years we will at some point be able to explain, at the physicochemical level, the causal relationship between the lesion and the visual and auditory content of the delusion. Perhaps we will be able to find more associations, but finding an association, or a neural correlate, of the content of a delusion does not mean explaining its cause scientifically – in the form of a mechanistic model of causes, in which we can explain the cause step by step and predict what it will bring about and where.

At the same time, Szasz ignores problems that we today classify as mental problems and that are triggered only in specific cases in specific people. Mostly at some extremely tense moment in life. For example, various anxiety disorders or manias (trichotillomania, kleptomania, etc.) are triggered in a stressful situation. Stress is not their real cause (and in the light of the previous paragraph this may be a very philosophical question); we speak of existing predispositions. Yet without a specific trigger, the predisposition might never manifest itself. What kind of problem is this? Purely of the brain? Purely social? Purely of personality? It seems to be somewhere in between, and so going the other way, too, and reducing all mental disorders to problems of the brain appears to me to be a mistake. We will never find anxiety triggered by an external trigger in the brain itself. It is a mental problem that is an emergent manifestation in behaviour, arising from the interaction of genes, the personality make-up of the person in question (an anxious nature) and social influences (e.g. preparing for an exam). In this case Szasz can rely neither on a reduction “downwards” to the brain, nor on a reduction “upwards”, that is, to the purely personal make-up of the person and the influences of society.

So yes, Szasz is right that psychiatry uses subjective methods, to a certain extent and, for Szasz, to too great an extent, to assess whether a patient is mentally ill. These assessments are necessarily conditioned socially, culturally, legally; in other words, value judgements, and therefore ethical judgements, creep into the seemingly exact assessment of an expert with a medical degree. And yes, tracking down the specific cause of delusional beliefs may be a scientifically as well as philosophically impossible task. Nevertheless, the author’s view that delusions cannot be caused by problems in the brain is in all likelihood incorrect.

Problems in living and the psychotherapeutic approach

Where I agree with the author is in the view that a certain subset of the problems that are today labelled mental disorders can be placed in an existential category: how to cope with the basic question of life, namely how to live. I call this type of problem the psychotherapeutic approach to problems in living because I understand Szasz’s argument to say that some form of psychotherapy or “coaching” is the right method for treating these existential problems, which medicine, according to Szasz, wrongly takes the liberty of calling mental disorders.

The psychotherapeutic approach, in my view, is oriented towards themes similar to those we find in existentially minded psychotherapy, whose roots go back to the phenomenology that grew out of the work of the German philosopher Martin Heidegger. Heidegger and others dealt with the idea that the basis of our human existence is the fact that into the world we are thrown:

“But to ‘being-in-the-world’ belongs the fact that – delivered over to itself – it has always already been thrown into a certain world”

(Bytí a čas, §41. Bytí pobytu jako starost, p. 221)

This thrownness (Ger. Geworfenheit) designates the givenness of our existence. We found ourselves in the world without our doing, and we belong to a particular culture, to relationships and to historical moments. The Frenchman Merleau-Ponty would add that we also have certain bodily dispositions that shape our relationship to other people and to the world in general. In other words, we are born into a life we did not choose, and we have to exist in it somehow. The more complex the society we live in, the more varied the problems we have to deal with. Some cope with life better, some worse. Some start with themselves; others see the primary problems in social structures and political variables, which we have likewise inherited.

Szasz considers himself a radical individualist. Or at least that is how he appears to me. For his psychotherapeutic approach to solving existential problems is a radical responsibility for oneself, based, in the author’s words, on a rational understanding of one’s own situation and on following the appropriate steps based on that understanding. Szasz believes that the solution to all our problems is within reach, and that only our individual responsibility for our actions will lead to the solution of our existential problems and our pseudo-mental disorders.

Szasz flatly refuses to see the origin of the complexity and difficulty of our lives in higher structures, for example political and social structures. In his article, however, he does not explain why he ignores these higher structures.

The author does explicitly deny that he is founding any school of psychotherapy. Even so, he offers a concrete recipe for better mental health. The problem, according to him, is choice. And the choices we make during our lives affect our mental health. If we choose well, we are better prepared to cope with the complexity of our lives. What does well mean? As has already been said, our choices must be based on a rational approach, and we must have the best possible understanding of our life situation, because only then will we be able to make not random but rational choices, which should, hopefully, lead to a better life and mental well-being. Our mental health is directly proportional to the quality of our life choices and to how rationally we make them.

Summary

In his influential 1960 article The Myth of Mental Illness, Thomas Szasz claims that mental disorders are a myth and as such do not exist. For mental disorders can either be reduced to physicochemical problems in the brain (and so they are problems of the brain), or they are pseudo-mental disorders, which are rather problems in living, that is, of coping with the complexity of life.

The author goes on to analyse these pseudo-mental disorders through two approaches, which I call ethical and psychotherapeutic. The first points to the ethical, value-relativising dimension of psychiatrists’ work, in which the psychiatrist’s worldview, cultural background and subjective impressions often decide whether a given utterance will be assessed as a mental disorder or not. The author thereby points out that medicine in general and psychiatry in particular are not value-neutral exact sciences, but are inevitably dependent on the subjective judgements of psychiatrists.

By the psychotherapeutic approach I mean a type of critique of the field of psychiatry in which the author sees mental disorders as existential problems of living in society. Although the author explicitly denies wanting to create a new school of psychotherapy, he nevertheless offers an analysis of existential problems and a possible remedy which, in my opinion, represents a form of psychotherapeutic analysis and intervention. Specifically, the author thinks that people can reduce the mental problems caused by the complexity of life if they make rational life choices based on an understanding of their life situation. The author places the blame for mental problems on the individual’s bad individual decisions. This radical individualism ignores the possible influences of higher structures – society, the political system, historical circumstances, etc. According to the author, our mental health is directly proportional to the quality of our life choices and to how rationally we make them. Szasz’s critique thus remains a call to reflect on the very foundations of psychiatry – that is, on the question of whether “mental illness” denotes a real entity, or rather a set of our cultural judgements about how a person ought to live. And if we accept the existence of mental disorder, a fruitful question for the philosophy of psychiatry is where exactly to look for its causes.

Philosophy of Psychiatry — a three-part series:

  1. “no human activity is devoid of human value”, p. 115 ↑
  2. p. 116 ↑
  3. “On the other hand, a person’s belief–whether this be a belief in Christianity, in Communism, or in the idea that his internal organs are ‘rotting’ and that his body is, in fact, already ‘dead’–cannot be explained by a defect or disease of the nervous system.”, p. 113 ↑