Is Mental Illness a Disease; T. Szasz

The Therapeutic State Is Mental Illness a Disease? by Thomas Szasz "You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird.... So let's look at the bird and see what it's doing that's what counts. I learned very early the difference between knowing the name of something and knowing something." -RICHARD FEYNMAN T ipper Gore says that "One of the most widely believed and most damaging myths is that mental illness is not a physical disease. Nothing could be further from the truth." Similarly,the National Alliance for the Mentally III (NAMI), the most influential mental health lobby in the nation, states: "Mental diseases are brain disorders." Are these assertions true? And if they are, what are their logical and practical implications? I say that "mental illnesses" are not dis eases, despite the fact that medical and legal authorities call them "diseases," that they are treated with drugs, that those receiving these drugs are called "patients," and that the pro fessionals treating them are called "physi cians." Why do I say this? Because the estab lished scientific criterion for disease is a derangement in the structure or function of cells, tissues, and organs-a criterion mental illnesses fail to meet, as they can be neither detected nor diagnosed by examining cells, tissues, or organs.

Rather, mental illnesses are identified by Thomas Szasz, M.D., is the author of The Myth of Mental Illness. He wishes to thank Alice Michtom, M.D., for help in the preparation ofthis column. 38 certain behaviors, and what concerns Mrs. Gore, NAMI, and others is not the theoretical question of what counts as a disease, but the practical problems posed by these behaviors. In fact, whether a person who has a disease feels well or ill, accepts or denies that he is ill, consults a doctor or not, benefits from or is harmed by drugs are all issues important to the practice ofmedicine but not to the defini tion of disease. Likewise, whether a person obeys or breaks the law is irrelevant to the definition of disease. Disease is a physical concept and verifiable phenomenon. Accord ingly, gastroenterologists study the abnormal states of the digestive system-not gluttony. Urologists study the abnormal states of the genito-urinary system-not prostitution.

Neurologists study the abnormal states of the brain and nervous system-not murder or sui cide. What do psychiatrists study? Do they, as Nancy Andreasen, professor of psychiatry at the University of Iowa, puts it, study "the brain rather than the mind, ... molecules and chemical transmitters rather than drives and fantasies"? Or do they, as Shakespeare put it, study the persons who suffer "the slings and arrows of outrageous fortune"? This is the crucial distinction masked by equating brain with mind. If "mental illness" means brain disease, then it is not a disease of the mind and psychiatry would be absorbed into neu rology and disappear. But this is patently not the case. Psychiatrists regularly occupy them selves with personal conduct of social inter est, such as homosexuality, aggression, racism, suicide, and murder. Expanding "Disease" It is an elementary principle of logic that one cannot prove a negative. One cannot prove the nonexistence of mental illnesses, just as one cannot prove the nonexistence of ghosts. One can only point out that a belief in mental illness as a disease of the brain is a negation of the distinction between persons as social beings and bodies as physical objects, in the same way that a belief in ghosts is the negation of the distinction between life as activity and death as the cessation of it. What happens when we negate the distinction between social beings and physical objects is that the concept of disease ceases to be limit ed to the dysfunction of cells, tissues, and organs and is expanded to include "dysfunc tional" conduct, especially behavior people in authority find troublesome.

Interestingly, the pioneers of psychiatry understood this distinction, accepted that the scientific concept of disease was restricted to the malfunction of the body, and acknowl edged that the term "mental illness" was a fig ure of speech. In 1845, the Viennese psychia trist Ernst von Feuchtersleben (1806-1849) wrote: "The maladies of the spirit (Geist) ... can be called diseases of the mind only per analogiam. They come not within the juris diction of the physician, but that of the teacher or clergyman, who again are called physicians of the mind only per analogiam." And in his classic, Lectures on Clinical Psy chiatry (1901), Emil Kraepelin (1856-1926) -who created the first modem classification of mental diseases-acknowledged: "It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased." In short, a sick mind, like a sick economy, is a metaphor. 39 Mind Is Not Brain Treating the metaphor as the thing itself the metaphorization of disease, in our case has led to the confusion of production with product, person with body, and mind with brain. Note that unlike the term "brain," the term "mind" implies agency, intentionality, and motivation. Accordingly, behavior per se that may result in disease is often categorized as a mental disease, but is never categorized as a medical disease. For example, excessive drinking is considered a mental disease, not a gastrointestinal disease-though cirrhosis of the liver is. A competent speaker of English may thus assert that schizophrenia has caused a person to kill an innocent bystander and excuse him of his deed, but he would never say that diabetes has either caused such law less behavior or excuses it. Herein lies one of the most important philosophical-political consequences of the concept of mental ill ness: it removes, with one fell swoop, motiva tion from action, encompasses it within ill ness, and thus destroys the very possibility of separating disease from non-disease, since it offers the possibility that any intentionality or motivation is a potential "disease."

In 1924, the great Eugen Bleuler (1857 1939), the inventor of schizophrenia, declared: "Those who simulate insanity with some cleverness are nearly all psychopaths and some are actually insane." The idea that pretending to be ill is, itself, an illness became socially acceptable during World War II and has since become psychiatric dogma. Kurt Eissler (1908-1999), a world-famous psycho analyst and psychiatrist, framed the doctrine thus: "It can be rightly claimed that malinger ing is always the sign ofa disease." Behavior is not-and cannot be-a disease, except in psychiatry. Controlling behavior, with or without a person's consent is not and cannot be-a treatment, except in psychi atry. And faking illness is not-and cannot be-an illness, except in psychiatry. Paradoxically, the intellectual bankruptcy of the idea of mental illness is the pillar on which modem psychiatry-and the therapeu tic state-rest. Credo quia absurdum est. D The GrowingAbundanceof FossilFuels by Robert L. Bradley, Jr.