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There are several examples by means of which Szasz tries to show that "mental illness" is a myth because its logical foundations are in error. The first of these is based on the logic of classification: if illness is a class of phenomena, say A, then there must be a class of non-A (some of these may look like A but turn out not to be) and a class of counterfeit-A, "similarity in appearance being deliberately created by a human operator for some purpose" (p. 39). The use of hysteria as a paradigm is crucial to Szasz's point here, because although it may look like physical illness ( A ) it has no organic basis and must logically be distinguished from A. So it is a logical error to place hysteria, as imitation of illness, in the class of illness itself.
For this to be so we must accept two assumptions made by Szasz: (1) that there are only two options in classifying someone who exhibits symptoms of physical disorder: "a person who complains of bodily symptoms may be a 'sick patient' or a 'healthy malingerer' " (p.39), and (2) that Charcot and Freud, in classifying the hysteric as ill were in fact placing him in the same logical class as those with physicochemical disorders of the body. But Charcot and Freud recognized that hysteria only appeared to be physical illness; they did not illogically place it in class A (physical illness), but in a special class of non-A (non-physical illness) called "mental illness." Before their time hysteria was more or less considered one with malingering (counterfeit-A). However their distinction between the two rested on the logical fact that not all non-A, and not even all imitations of A, are counterfeit-A.
A second example based on the logic of classification is the later development in psychiatry of classifying malingering itself as mental illness, a move which Szasz contends denies the possibility of imitation, i.e., counterfeit-A is accepted as A. Again this reflects his refusal to accept mental illness as a distinctive category in the class "illness." If we call physical illness A and mental illness B, and further distinguish within both various kinds of illness (A1, A2, B1, B2, etc.), then, e.g., B5 is malingering, i.e., deliberate imitation of another kind of illness. This does not deny the possibility of imitating, but proposes that in certain situations, (we would distinguish between the faked illness of children playing hospital and that of a man who hates his job) conscious imitation of illness is not, by a given standard, the appropriate way to deal with a problem.
Szasz also wants to show an epistemological error at the base of Freud's theory. To explain conversion hysteria Freud relied on a physical model of energy discharge. Says Szasz, "no such complicated explanation is required" (p. 82); the problem is "epistemological rather than psychiatric. In other words there is no problem of conversion unless we insist on so framing our questions that we inquire about physical disorders where, in fact, none exist" (p. 83).
It is Szasz's conviction that the traditional mind-body problem can and should be avoided in psychiatry: "We shall not regard the relationship between the psychological and physical as the relationship between two different types of events or occurrences, but shall rather consider it to be akin to two different modes of representation or language" (p. 83). Accordingly, Freud's physical model of energy discharge should be replaced by thinking of what happens in terms of translation from one language to another.
There are two objections to this: (1) The error to be seen in Freud's thinking is pointed up by reference to Szasz's own theory ("it should be re-phrased this way because it can be"); and (2) We are still left with the problem of explaining by what means a nonphysical problem is changed into physical bodily "language" which can be distinguished from "real" body "language" (real physical illness). Because he objects to Freud's mechanical explanation, Szasz maintains that it is an epistemological error to seek explanation for an "apparent" mind-body problem. His thinking here can be traced to his contention that there is no place for (causal) explanations in psychiatry.
"MENTAL ILLNESS" AS DISEASE ENTITY
There are two aspects to Szasz's argument that "mental illness" does not denote a disease entity, one medical-logical and the other social. First of all, Szasz chooses to define "disease entity" as bodily disorder (pp. 101-02), thereby ruling out any other than physical disorder as well as any other than physical entities counting as disease. In any case, his position that physical illness, e.g., the common cold, denotes "an entity found in nature" whereas hysteria (and mental illness in general) is "an abstraction or theoretical construct made by man" (p. 88) is erroneous. The common cold is not "an entity found in nature"; it is not, as Szasz implies, an observable phenomenon, although its symptom-complex is. "Common cold" is a term, such as "hysteria," under which its specific symptoms can be subsumed. The crucial difference, of course, is in the nature of the symptoms, a point which Szasz does not discuss. (After all, if there is no such thing as mental illness then there are no symptoms of mental illness.) Instead he bases his argument on a discussion of physical symptoms (again his choice of paradigm is crucial), but of physical illness.
Szasz carefully points out that in physical medicine there are three types of symptoms: bodily complaints, bodily signs, and empirical evidence of functional or structural alteration of the body. "Illness," logically, is an inference from some combination of these, generally including the last. But he makes a crucial jump here. The logic of medical diagnosis requires the last type of symptom as a justification for inferring that the patient's complaint in fact indicates organic disorder, not, as he argues, as a verification of the first type of symptom. In analyzing hysteria Szasz assumes that since there is no organic basis for the patient's complaint, the referent of the complaint, e.g., pain, is not real; the patient is lying. (Note his bias: only publicly observable evidence counts.)
This is why he says that Freud made an epistemological error in inquiring about a nonexistent physical disorder, and that hysteria is only imitation. Freud, and psychiatrists in general, do not commit the logical error of inferring organic disorder only on the basis of the "subjective" evidence of bodily complaint; they do not infer organic disorder. They do however accept the patient's report of pain, and finding no organic basis for it infer that it requires psychological explanation.
From a social analysis, too, Szasz believes we can conclude that the terms "hysteria" and "mental illness" do not denote a disease entity. "Actually they arise from and reflect characteristic features of the social matrix of the therapeutic situation" (p. 296). To support this he compares medical systems in the U.S. and the Soviet Union, showing that in the first instance the psychotherapist is the patient's agent whereas in Russia the physician is the agent of the state. He then cites statistics of increasing diagnosis of mental illness in the United States in contrast to a high incidence of malingering in the Soviet Union. From this he concludes that "mental illness" reflects a social condition, but not a disease entity.
In the first place there is an assumption that the same "somethings" are being presented in the two countries and are only being diagnosed differently. Second, he is interpreting a high statistical correlation of two phenomena as evidence for a causal relationship, in this case, that agent-pattern determines diagnosis-pattern. Third, is the assumption that social conditions can tell us something about the nature of the subject, i.e., whether there is a disease entity that can be called "mental illness." But this is like drawing conclusions about the intelligence of children by looking at the various types of education provided them because of varying social contexts. Neither on the basis of this social argument nor of the logic of diagnosis can we conclude that "mental illness" does not refer to a disease entity.
This concludes the discussion of Szasz's attempt to show that "mental illness" is a myth. Without ignoring that Szasz has touched upon some of the crucial problems which complicate our use of the concept, e.g., personal responsibility and the deterministic model of causality, his arguments do not support the conclusion that "mental illness" is a myth, i.e., nonexistent or illogical.
HOW VIABLE IS THE ALTERNATIVE?
Szasz proposes three explanatory models to replace the current mental illness concept (and to explain all of human behavior). They are the sign-using, rule-following, and game-playing models. He offers a detailed analysis particularly of the first, showing the types and functions of language (signs) and relating hysteria (as paradigm) to these and to specific social rules. He then shows how hysteria can be considered a game. Since he sees it as the most comprehensive model, I will point out some general objections to game-playing as a theory of behavior, then discuss the implications of his explanation in two areas: intention and personal responsibility.