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Related to the above is Szasz's point that "psychiatrists cannot expect to solve ethical problems by medical methods" (p. 8). Underlying this is his contention that a so-called mental illnesses are really problems in living, i.e., ethical problems. Even if we accept this, what constitutes "medical methods" remains unclear. If he means to argue against the organicists who hope to eventually solve all mental illnesses by medical means or against such things as the present increase in prescribing mood-changing drugs, then he has a point. But his implication is that all psychiatrists who practice as doctors or in a medical situation are, and should not be, using "medical methods" (all of traditional methods? some of them?).
Szasz presents Freud as a prime example of the above:
"Problems in living . . . were thus treated as though they
were manifestations of physical illnesses" (p. 75). But
just the opposite is the case.
Freud, in the problem of hysteria with which his work began, took the apparent manifestations of physical illness and treated them as though they arose from conflicts in life situations. He used the "talking cure" which is not a traditional medical method. And for the most part psychiatrists, although they regard what they treat as illness, primarily employ other methods than those characteristic of physical medicine. So it seems that Szasz is demolishing a straw man.
On the basis of the arguments presented it is not necessary to disengage psychiatry from medicine, particularly as regards the scientific foundations and the specific methods of the two fields. The issue of whether our use of "mental illness" and "responsibility'' are mutually exclusive is less conclusive. However, it is not impossible to think, even in some illnesses of the body, of the person being directly or indirectly responsible or culpable for bringing on or encouraging his own illness. So a tentative proposition might be suggested, that although the tendency has been to greatly overuse "mental illness" as an excusing concept, it is possible to re-think without discarding the notion of mental illness.
IS MENTAL ILLNESS A MYTH?
The greater part of Szasz's effort to debunk "mental illness" is spent in an attempt to show that it has no valid scientific foundations; it cannot be rationally justified; it is a myth. The arguments for this conclusion can be summarized in these four points: 1) Since what psychiatrists really deal with is "problems in living" they should stop talking about "mental illness" and re-define their field; 2) Psychiatry began with the studies of hysteria by Charcot and Freud, who classified it as a disease for social and historical, i.e., nonscientific, reasons; 3) In the classic fiction of hysteria as mental illness logical distinctions were obscured and epistemological errors made, and the same type of errors are perpetuated in subsequent classification; 4) "Mental illness" does not denote a disease entity; use of the concept is therefore an attempt to explain "problems in living" in terms of a myth.
I will not deal with the second argument since it relies on psycho-historical explanation. That is a kind of deterministic model itself and defeats one of the purposes given by Szasz for arguing against "mental illness." In addition, its importance is unclear since the "scientific" status of a theory, model, or type of explanation does not rest on the historical factors involved in its origin.
A note is in order here regarding Szasz's use of conversion hysteria as the paradigm of mental illness. He contends that whatever can be said about hysteria "pertains equally, in principle, to all other so-called mental illnesses and to personal conduct generally" (p. 9) since the diversity of mental illnesses is analogous to the diversity of languages. There are several difficulties with Szasz's choice of paradigm. (a) Hysteria is not a "typical" mental illness in that it (uniquely) involves functional disorder of the body. It is somewhere between uncomplicated physical illness and uncomplicated mental illness. As such, what is concluded about its correct or incorrect classification as mental illness may not be particularly relevant in a consideration of the general validity of "mental illness" as a category. (b) Szasz hopes to bridge this gap by comparing the diverse mental illnesses to languages. Although he develops in great detail and with some success the idea that hysteria is (is like? we're not quite sure) a language, it is never clear how we are to take the step from this to all mental illnesses are (are like?) languages.
At many points Szasz tries to underline his thesis by showing that the issues can be (and therefore should be) re-stated in terms of his own theory that behavior is communicational and rule-following and game-playing. Since Szasz offers his own model not only as an alternative to take the place of the one he is attempting to invalidate, but also as supporting reason for abandoning it, much of his argument depends on its explanatory value. This will be taken up later, but some of its shortcomings will become apparent already in looking at his arguments against "mental illness."
First, we are to see that "mental illness" is a myth by examining what it is that psychiatrists do. The traditional definition of psychiatry is: the branch of medicine dealing with disorders of the mind, including neuroses and psychoses. But what psychiatrists really do is "communicate with patients by means of language, nonverbal signs, and rules" (p. 3). Thus his characterization of psychiatry: the discipline whose method is communication—in its broadest sense (p. 3). More formally, psychiatry "consists of the study of personal conduct—of clarifying and 'explaining' the kinds of games people play with each other" (p. 7), and is differentiated from psychotherapy, which consists of the alteration of human behavior.
There are several problems here. First, Szasz takes the value of the first definition to be its reference to methodology rather than subject matter; it is an operational definition and therefore scientific (p. 2). But physics and biology, e.g., are defined in terms of subject matter, not the physicists' or biologists' methods or tools of study and intervention. Operational definitions are used within a science but defining the discipline itself is an extra-scientific problem. What Szasz hoped to accomplish with this move was to do away with the subject matter of the traditional definition.
His second definition, rather than excluding the subject matter, re-defines it as personal conduct (games). The problem with this is that is obscures an important distinction between psychiatry and psychology by including in the former all of behavior rather than the abnormal. Thus the traditional definition of psychology (the science dealing with the mind and mental processes, feelings, etc.) is ignored and implicitly done away with also. A strategic move for Szasz because in this way, with no opening left to talk of mind, mental processes, etc., there is no opening to talk of something going wrong there, i.e., of mental illness.
According to Szasz "personal conduct may be studied fruitfully by considering man's 'mind' mainly as a product of his social environment" (p. 13, emphasis added). This turns out to be a position much like that of the behaviorists who contend that, at least for the purpose of scientific study, the mind of man, if it exists, is a by-product (for the reductionists, a by-product of physical processes). So we can't talk about the influence of mind on body or body on mind or mental illness. There are only different languages, different games. The latter are descriptions of directly observable behavior and it is in keeping with Szasz's notion of science that this is the proper subject matter of psychiatry-psychology.
Granted that there are problems with the one sidedness of the subject matter designated by the traditional definition , excluding the defining characteristic of human beings rather than expanding the definition to include more aspects is not the best solution. In any case this re-definition with no mention of mind or mental processes does not show that "mental illness" is a myth. It merely defines it out of existence, at the expense of some important distinctions.
THE LOGlC OF "MENTAL ILLNESS"