For some time now the concept of mental illness and its corollary, an alliance between medicine and psychiatry, have come under attack from various sources. Dr. Thomas Szasz has been one of the first and one of the most outspoken of the critics. It will be the purpose of this paper to critically examine his book THE MYTH OF MENTAL ILLNESS, which Szasz considers fundamental to much of his later work. I will try to show that the arguments he presents against the mental illness concept are, in the last analysis, inadequate and that there are important shortcomings in his alternative theory of behavior. I shall also consider some of the implications of his position for several traditional problems in the field of psychiatry.
I want to make it clear that what I am not taking issue with is Szasz's point, made in THE MYTH OF MENTAL lLLNESS and brought out emphatically in subsequent publications, that involuntary commitment of mental patients is an abuse of the human right to liberty. Dr. Szasz instigated and contributed a great deal to the recent changes in some of the laws violating that right. Although he would probably disagree, I think that is a separate issue and ought to be argued on a different basis from the contention that "mental illness" is a myth—it therefore does not stand or fall with the arguments for the latter.
THE FORM OF SZASZ'S ARGUMENT
Before approaching the reasons Szasz offers for rejecting "mental illness" as a myth, it is important to understand the objectives he has in mind and his view of science. Szasz is arguing from within two current movements in the field of psychiatry, one of which is to emphasize the moral and ethical nature of human behavior. His position is (along with others who argue in this direction) that the psychiatrist should make his values explicit in the therapeutic situation. He further contends that the notion'of mental illness is used as an obscuring label for what are really conflicts of everyday living, i.e., ethical conflicts.
The second movement with which he aligns himself is the current attempt to bolster the scientific foundations of psychiatry and psychology. There is considerable confusion these days within both as to what it means to be scientific in a study of human beings. Szasz clearly argues against reductionism. He not so clearly argues for a "liberal empiricism" (p. 92) by which a diversity of methods and languages is considered appropriate for science because of the diversity of subject matter from one discipline to the next. I contend it is "not so clearly" because this is the extent of his explicit discussion of the matter. Implicitly empiricism means, for him, adherence in science to observables which are publicly verifiable. It is my point here merely to state his position because it has a bearing on his treatment of the subject, e.g., what we can say about causes of human behavior, what constitutes the subject matter of psychiatry (and psychology), and the relevance of "subjective" as opposed to "objective" symptoms.
How does Szasz's conviction that "mental illness" is a myth tie in with his ethical and scientific orientation for psychiatry? According to him the particular scientific framework of traditional medicine, with which psychiatry is identified through usage of the concept,"mental illness," necessarily determines the scientific basis and precludes the ethical aspects of psychiatry. So if we agree that psychiatry should be (in some way) both scientific (in its own right) and ethical (value-oriented), then we have only to further agree that both are conditional upon divorcing psychiatry from medicine.
The premises and conclusion of this argument are tied in with Szasz's major point that there is no such thing as "mental illness": it is a myth,and therefore has no place in science; it is a mask for ethical problems, and should therefore be abandoned; if indeed there is no such thing as mental illness then, again, psychiatry has no place within medicine. So there are two broad issues to be considered here, first, whether the purportedly necessary relationship between medicine and psychiatry obtains and, second, whether Szasz's contention that "mental illness" is a myth is well-founded.
MEDICINE AND PSYCHIATRY
Szasz's objection to considering some of man's behavior within the "confines" of medicine arises because he insists that to speak of psychiatry as a branch of medicine is to identify the two in every significant respect. Then, since medicine is grounded on the principles of physics and chemistry, psychiatry must be also. The latter is thus necessarily tied to a conceptual framework inappropriate for a scientific study of man.
This view depends on erroneously uniting two aspects of the concept of medicine. We can think of medicine as entailing both "treatment" and "(treatment) of what"; there is no necessary relationship between treatment as such and some specific object being treated. To say that medicine (physical) is treatment and corresponds to a body of scientific knowledge and to further assert that psychiatry is treatment is not to say that it is dependent on the same knowledge or facts. In other words the relationship between medicine and psychiatry need not be (and is not) one of identity in specific content or method.
Of course we cannot ignore the fact that a number of psychiatrists have preferred to limit themselves to the physicochemical framework of medicine with their belief in the eventual discovery of organic bases for all mental illness. But this is neither a necessary nor universal outcome of the assertion that psychiatry can be considered a branch of medicine which offers treatment for certain dysfunctions.
A second argument given is that the physicochemical framework of medicine commits psychiatry to a deterministic model of causality, thereby ruling out significant aspects of human behavior, namely, choice, responsibility, and valuation. This point is again dependent on Szasz's insistence on the identification of psychiatry and medicine. On this basis if one is to look for the cause of a behavioral disorder which is presented in a medical (i.e. psychiatric) situation, one is committed to looking for an organic, or at least a physical-mechanical (hence deterministic), explanation.
But if we recognize that psychiatry is not necessarily based on physics and chemistry because of its medical association, then we do not have to choose Szasz's solution, which is (in order to avoid determinism) to dismiss causality from psychiatry altogether. According to him if we re-define the problem in terms of different languages (instead of "mental illness"), then there is no need to search for causes. To understand another language we view it from the standpoint of learning and meaning, not causes and treatments. But there are problems with this dismissal, for we may not seek causes if, for example, a man grew up in France and speaks French, but if he grew up in Italy and we observe him speaking French we are inclined to look for causes.
Admittedly the idea of accountability and responsibility for one's actions and how this relates or cannot relate to the notion of mental illness is a fundamental issue for psychiatry. The problem for Szasz is that he implicitly accepts the Humean model as the only model of causality. In this he is like the behaviorists. Of course he differs from them in that he finds this model inappropriate to an explanation of human action. He therefore rejects it for psychiatry, but because he accepts only this one model of causality, this rejection leads him to deny the possibility (or appropriateness) of considering causes in a discussion of human action.
However, if causal explanations are ruled out by redefining the problem, it becomes difficult to talk, as Szasz wants to, about choice and responsibility. The latter concepts are dependent on the notion of personal causal efficacy in regard to one's own actions. And this is one kind of causality. So the alternative to determinism which Szasz offers is of dubious value for bringing ethical considerations into psychiatry.