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Thomas S. Szasz on the Myth of Mental Illness

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Thomas Stephen Szasz is a prominent leader of the anti-psychiatry movement.  These comments are excerpts from an article published in The American Psychologist in 1960.


My aim in this essay is to raise the question "Is there such a thing as mental illness?" and to argue that there is not. Since the notion of mental illness is extremely widely used nowadays, inquiry into the ways in which this term is employed would seem to be especially indicated.  Mental illness, of course, is not literally a "thing" -- or physical object -- and hence it can "exist" only in the same sort of way in which other theoretical concepts exist. Yet, familiar theories are in the habit of posing, sooner or later -- at least to those who come to believe in them -- as "objective truths" (or "facts").  During certain historical periods, explanatory conceptions such as deities, witches, and microorganisms appeared not only as theories but as self-evident causes of a vast number of events.  I submit that today mental illness is widely regarded in a somewhat similar fashion, that is, as the cause of innumerable diverse happenings.  As an antidote to the complacent use of the notion of mental illness -- whether as a self-evident phenomenon, theory, or cause--let us ask this question: What is meant when it is asserted that someone is mentally ill?
The notion of mental illness derives it main sup- port from such phenomena as syphilis of the brain or delirious conditions-intoxications, for instance -- in which persons are known to manifest various peculiarities or disorders of thinking and behavior. Correctly speaking, however, these are diseases of the brain, not of the mind.  According to one school of thought, all so-called mental illness is of this type.   The assumption is made that some neurological defect, perhaps a very subtle one, will ultimately be found for all the disorders of thinking and behavior.  Many contemporary psychiatrists, physicians, and other scientists hold this view.  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.
The crux of the matter is that a disease of the brain, analogous to a disease of the skin or bone, is a neurological defect, and not a problem in living. For example, a defect in a person's visual field may be satisfactorily explained by correlating it with certain definite lesions in the nervous system.  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.

Many people today take it· for granted that living is an arduous process.  Its hardship for modern man, moreover, derives not so much from a struggle for biological survival as from the stresses and strains inherent in the social intercourse of complex human personalities.  In this context, the notion of mental illness is used to identify or describe some feature of an individual's so-called personality.  Mental illness -- as a deformity of the personality, so to speak -- is then regarded as the cause of the human disharmony. It is implicit in this view that social intercourse between people is regarded as something inherently harmonious, its disturbance being due solely to the presence of "mental illness" in many people. This is obviously fallacious reasoning, for it makes the abstraction "mental illness" into a cause, even though this abstraction was created in the first place to serve only as a shorthand expression for certain types of human behavior.

The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm deviation from which is regarded as mental illness?  This question cannot be easily answered.  But whatever this norm might be, we can be certain of only one thing: namely, that it is a norm that must be stated in terms of psycho-social, ethical, and legal concepts.  For example, notions such as "excessive repression" or "acting out an unconscious impulse" illustrate the use of psychological concepts for judging (so-called) mental health and illness.  The idea that chronic hostility, vengefulness, or divorce are indicative of mental illness would be illustrations of the use of ethical norms (that is, the desirability of love, kindness, and a stable marriage relationship).
These considerations underscore the importance of asking the question "Whose agent is the psychiatrist?" and of giving a candid answer to it (Szasz, 1956, 1958).  The psychiatrist (psychologist or nonmedical psychotherapist), it now develops, may be the agent of the patient, of the relatives, of the school, of the military services, of a business organization, of a court of law, and so forth. In speaking of the psychiatrist as the agent of these persons or organizations, it is not implied that his values concerning norms, or his ideas and aims concerning the proper nature of remedial action, need to coincide exactly with those of his employer.  For example, a patient in individual psychotherapy may believe that his salvation lies in a new marriage; his psychotherapist need not share this hypothesis. As the patient's agent, however, he must abstain from bringing social or legal force to bear on the patient which would prevent him from putting his beliefs into action. If his contract is with the patient, the psychiatrist (psychotherapist) may disagree with him or stop his treatment; but he cannot engage others to obstruct the patient's aspirations.
Psychiatry, I submit, is very much more intimately tied to problems of ethics than is medicine. I use the word "psychiatry" here to refer to that contemporary discipline which is concerned with problems in living (and not with diseases of the brain, which are problems for neurology).  Problems in human relations can be analyzed, interpreted, and given meaning only within given social and ethical contexts. Accordingly, it does make a difference -- arguments to the contrary notwithstanding -- what the psychiatrist's socioethical orientations happen to be; for these will influence his ideas on what is wrong with the patient, what deserves comment or interpretation, in what possible directions change might be desirable, and so forth.

This is not the place to consider in detail the similarities and differences between bodily and mental illnesses.  It shall suffice for us here to emphasize only one important difference between them: namely, that whereas bodily disease refers to public, physicochemical occurrences, the notion of mental illness is used to codify relatively more private, sociopsychological happenings of which the observer (diagnostician) forms a part.  In other words, the psychiatrist does not stand apart from what he observes, but is, in Harry Stack Sullivan's apt words, a "participant observer."  This means that he is committed to some picture of what he considers reality -- and to what he thinks society considers reality -- and he observes and judges the patient's behavior in the light of these considerations.
For it seems to me that -- at least in our scientific theories of behavior -- we have failed to accept the simple fact that human relations are inherently fraught with difficulties and that to make them even relatively harmonious requires much patience and hard work. I submit that the idea of mental illness is now being put to work to obscure certain difficulties which at present may be inherent -- not that they need be unmodifiable -- in the social intercourse of persons.  If this is true, the concept functions as a disguise; for instead of calling attention to conflicting human needs, aspirations, and values, the notion of mental illness provides an amoral and impersonal "thing" (an "illness") as an explanation for problems in living (Szasz, 1959).  We may recall in this connection that not so long ago it was devils and witches who were held responsible for men's problems in social living.  The belief in mental illness, as something other than man's trouble in getting along with his fellow man, is the proper heir to the belief in demonology and witchcraft.
My aim is more modest and yet also more ambitious. It is to suggest that the phenomena now called mental illnesses be looked at afresh and more simple, that they be removed from the category of illness, and that they be regarded as the expressions of man's struggle with the problem of how he should live.